|Year : 2021 | Volume
| Issue : 3 | Page : 328-334
Knowledge and perceived ability to deal with physical comorbidities in substance use disorders: Does participation in continuing medical education help?
Nidhi Sharma1, Abhishek Ghosh2, Renjith R Pillai2, BN Subodh2, Debasish Basu2, Surender Kumar Mattoo2, Aniruddha Basu3, Raghav Shah4, Fazle Roub2
1 Department of Psychiatry, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 Department of Psychiatry, MJ Rajasthan Hospital, Jaipur, Rajasthan, India
|Date of Submission||19-Jul-2020|
|Date of Decision||13-Sep-2020|
|Date of Acceptance||23-Sep-2020|
|Date of Web Publication||30-Sep-2021|
Dr. Abhishek Ghosh
Department of Psychiatry, Drug De-Addiction and Treatment Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: Despite the magnitude and impact of co-occurring physical and substance use disorders (SUDs) and evidence of effectiveness of integrated care, the training for management of comorbidities has been neglected. Our objective was to examine the effectiveness of 1-day continuing medical education (CME) in this area on participants' perceived and objective knowledge and skills. Materials and Methods: It was a cross-sectional study of CMEs conducted in a tertiary care center with a pre-post assessment design. Assessment included rating perceived knowledge and skill on a five-point scale and objective multiple-choice questions. Subjective feedback on qualitative aspects of the CME was taken. Out of total 154 participants, 69 completed pre-post assignments that included interactive lectures through multimodal presentations and problem-based learning. Pre-post comparisons were done by paired t-test and Wilcoxon signed-rank test. Results: Pre-CME assessment showed low mean scores (4.04 [1.75]) in objective (assessment to be added) and limited perceived knowledge and ability. However, objective knowledge assessment showed a significant improvement (P < 0.001) after the CME. Perceived knowledge and skills showed a significant positive (P < 0.001, all comparisons) change in all the four (CME-1) and seven (CME-2) domains assessed. CME was perceived to be excellent in terms of the practical value of material (60.3%), able to meet its stated objectives (60.3%), quality of instructions (58.8%), and organization of material (60.3%). Conclusion: CME is a viable option for training of psychiatrists to address the unmet need for treating co-occurring physical and SUDs. Future studies with experimental designs should determine the effectiveness of the components of CMEs.
Keywords: Comorbidity, substance use disorder, training
|How to cite this article:|
Sharma N, Ghosh A, Pillai RR, Subodh B N, Basu D, Mattoo SK, Basu A, Shah R, Roub F. Knowledge and perceived ability to deal with physical comorbidities in substance use disorders: Does participation in continuing medical education help?. Indian J Soc Psychiatry 2021;37:328-34
|How to cite this URL:|
Sharma N, Ghosh A, Pillai RR, Subodh B N, Basu D, Mattoo SK, Basu A, Shah R, Roub F. Knowledge and perceived ability to deal with physical comorbidities in substance use disorders: Does participation in continuing medical education help?. Indian J Soc Psychiatry [serial online] 2021 [cited 2022 Jun 28];37:328-34. Available from: https://www.indjsp.org/text.asp?2021/37/3/328/327282
| Introduction|| |
Research has consistently shown a high occurrence of physical comorbidities among people seeking treatment for substance use disorders (SUDs).,,, A higher prevalence of infectious diseases (human immunodeficiency virus [HIV] and hepatitis) and chronic medical diseases (hypertension, diabetes, and chronic liver disease) has been reported in substance users. The National Recovery Survey of the US showed that more than one-third of the participants who were in remission from alcohol and drug use had at least one of the nine physical comorbidities: alcohol-related liver disease, hepatitis C, tuberculosis (TB), HIV, or acquired immune deficiency syndrome, other sexually transmitted diseases (e.g., gonorrhea), chronic obstructive pulmonary disease (COPD), cancer, heart disease, and diabetes. Results also showed that the prevalence of most of these diseases was more in the population with SUDs, compared to the general population. Thus, physical comorbidities continue to affect people even when they stop consuming alcohol and other drugs of abuse. In addition to medical comorbidities, chronic pain and substance use have a significant association and a complex relationship.,
This increased risk of comorbidity between SUD and physical illness is associated with more severe functional impairment and a higher health-care cost, greater impairment in the quality of life, negatively influences treatment adherence to the medical conditions, and might also decrease the effectiveness (efficacy) of the medications prescribed., An integrated care approach gives an opportunity to the mental health professionals to work in liaison with medical internists and improve the overall health outcome.
Despite the magnitude, severity, and impact of the comorbidity and evidence of effectiveness of integrated care, the training for the screening and initial management of physical comorbidities has been neglected in psychiatric practice.
Continuing medical education (CME) offers the scope “to maintain, develop, or increase the knowledge, skills, and professional performance and relationships” that a physician uses to provide services for patients, the public, or the profession. The present study examined the effectiveness of two CMEs held with the objectives of improving participants' (psychiatry residents and practitioners) knowledge and skills to detect and start initial management of common medical comorbidities in the presence of SUDs.
| Materials and Methods|| |
Setting and participants
This was a cross-sectional study of two CMEs, with pre- and postassessment of knowledge and perceived skills, among participants who attended two CME programs in April and September 2018. Both the CMEs were organized by the Drug De-Addiction and Treatment Centre of the Department of Psychiatry. Being part of a general hospital psychiatric unit, the CME organizers could involve various medical specialties relevant to the CMEs. The sample consisted of participants of the two CMEs. Participants were either qualified or trainee psychiatrists working in private or government setup. Ethical approval was sought from the Institutional Ethics Committee, and the study was approved vide letter number INT/IEC/2019/002155.
Description of the continuing medical educations
The 1-day CMEs were notified through individual E-mails to the head of the departments of psychiatry of various medical colleges of northern India, group E-mails to the professional bodies, and through the social networking sites.
CME-1 was held on April 7, 2018. The medical comorbidities focused were hypertension, diabetes, chronic liver disease, hepatitis C, epilepsy, cutaneous complications, and sexually transmitted diseases. The resource persons were from the departments of internal medicine, gastroenterology, hepatology, neurology, and dermatology. There were more than 3 h of interactive case vignette-based sessions on management of SUDs in the presence of liver disease, hepatitis C infection, diabetes, and epilepsy. The sessions were conducted by a faculty from the department of psychiatry. The total contact time for the CME was 5 h (excluding one lunch and two coffee breaks).
CME-2 was held on September 15, 2018. The first lecture was on HIV and SUDs by a professor of internal medicine and the program director of the center of excellence in HIV care. The second and third lectures were on hepatitis B and cardiac complications of SUDs, delivered by a cardiologist and a hepatologist, respectively. The fourth lecture, delivered by a professor of pulmonary medicine, was on COPD. The prelunch session ended with case vignette-based discussions, focusing on the practical aspects of management of injection opioid use, in the presence of medical comorbidities, such as HIV and hepatitis B. The postlunch session by a professor of anesthesiology focused on the management of chronic pain and judicious use of opioid analgesics. The total time and break profile of the two CMEs was similar.
For most of the presentations, learning objectives were mentioned upfront. The faculty had followed a case-based learning format. Rather than clinical guidelines, the faculty presented screening and management of the medical comorbidities in the realistic contexts. They also shared their clinical experiences. Sessions were interactive. The case vignettes included text, graphics, and video-based slides, and interactions were based on problem-oriented learning and were dependent on the active participation of the audience. The presentation slides were E-mailed to participants who asked for those. The CME-2 was recorded, and all the sessions were uploaded on the institute's website.
Participation was solicited explaining the purpose of the study as evaluating the effectiveness of the CMEs. Informed consent was obtained. The career details – age, gender, institution and place of training/work, and total duration of psychiatric practice (including training) – were recorded. The blank assessment tools were distributed and filled ones collected back in a stipulated time period before starting the CME and at the end of the CME. Detailed instructions regarding the questionnaire were announced before the distribution of questionnaire. Members of organizing team (experts in addiction psychiatry) also asked the participants, for any doubts regarding the instructions, while they were attempting the test and immediately clarified the same.
For objective assessment, participants were asked to answer ten multiple-choice questions (MCQs). These were drafted by one of the investigators and subject expert, AG. Then, the questionnaire was circulated and discussed with other investigators, NS and AB. After discussion, a consensus was reached about the numbers and type of questions to be included. For subjective assessment, one of the investigators and subject expert, AG, adapted the questionnaire from another paper, describing the methods of testing pre-post subjective knowledge. The questionnaire was circulated and discussed with other investigators, NS and AB. After discussion, a consensus was reached about the content of the questionnaire. It rated the participant's level of knowledge about the subject and self-proficiency in managing comorbid medical complications in patients with SUDs. It was a five-point Likert scale with a range from 0 to 4, where 0 and 4 signified no and significant level of perceived knowledge, respectively. Both these assessments were carried out twice, at the beginning and the end of the CME. The participants were also asked to rate the CME in the following domains: quality of instructions, organization of material, practical value of the material, and whether the activity met its stated educational objectives. Rating ranged from excellent to poor in a four-point Likert scale. The clarity of instructions and the overall quality of the CME were assessed (rated on a scale of 1–5, low to high).
Session-wise knowledge assessment was done in both CMEs. The total number of sessions, topics, and the contents of the various sessions were not similar in the CMEs. Hence, two different questionnaires were developed. There were four knowledge items for the CME-1 and seven knowledge items for the CME-2. MCQs were also different in both CMEs. Questionnaires have been shared as supplementary material, panel 1 and panel 2.
Descriptive statistics such as mean, standard deviation, frequency, and percentage were used to describe the distribution of the data. Parametric data were compared using independent-samples t-test or Chi-square test. Nonparametric data were compared using Mann–Whitney U-test. A paired t-test was used to compare the pre-post (CME) mean scores of objective assessments. Likert scale was used to assess subjective knowledge and skills. Wilcoxon signed-rank test was used to compare paired variables before and after the CMEs. Distribution of the differences between the two related groups (pre- and post-CME evaluations) was checked by visual inspection of box plots. All analyses were done by the SPSS 17 software (PSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc).
| Results|| |
Both CME attendees totaled 233. Of these, 151 (64.8%) were evaluated (either preassessment or both pre- and postassessment). Among these 151 participants, 55% were men; the mean age was 31 years (standard deviation [SD]: 7.5 years; range: 25–65 years). They were in the psychiatric practice for 4 years (SD: 6.9 years). Almost 75% were working in medical colleges (mostly trainees). The remaining were almost equally divided between private and government hospitals. A comparison was done between two groups, i.e., participants of CME-1 and CME-2. Demographic profile of participants was similar in these two groups in terms of age (P = 0.67), years of practice (P = 0.255), and gender (P = 0.74) [Table 1].
|Table 1: Demographic and practice-related details of the participants of continuing medical education 1 and continuing medical education 2 who completed preassessment questionnaire|
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Total number of participants was 151. Sixty nine completed both pre and post assessments. Among the completers, 60% were males with a mean age of 30 years (SD: 7.6; range 25–52 years) and mean years of psychiatric practice of 3 years (SD: 3.5 years). Almost three-fourth were working in medical colleges, and the remaining were similarly divided across private practice and government hospitals. This profile was similar to 82 participants, who completed only preassessment [Supplementary Table 1].
In CME-1, 27 participants, who completed both pre- and postassessment pro forma, included 56% women and had a mean age of 29.4 years (SD: 6.4 years; range 25–52 years). They had mean years of psychiatric practice of 3.3 years (with a skewed distribution, SD: 3.8 years). Eighty-one percent were working at medical colleges (mostly trainees) and the remaining working at private and government hospitals. In CME-2, 42 participants, who completed both pre- and postassessment pro forma, included 70% of men and had a mean age of 31 years (SD: 5.8 years; range 25–45 years). The mean years of psychiatric practice was 2.8 years (SD: 3.4 years). Sixty-nine percent were working at medical colleges and 19% and 12% working at government hospitals and in private practice, respectively. A comparison was done between two groups, i.e., participants of CME-1 and CME-2. Demographic profile of participants in these two groups was similar in terms of age (P = 0.28), years of practice (P = 0.614), and gender (P = 0.18) [Table 2].
|Table 2: Demographic and practice-related details of the participants of continuing medical education 1 and continuing medical education 2 who completed both pre- and postassessment questionnaire|
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Knowledge and skills of the participants
Responses about perceived knowledge and skills in various domains were assessed in a scale ranging from no knowledge, very limited, some, moderate, and significant knowledge. In data analysis, variables of no knowledge, very limited, and some knowledge were clubbed together into “limited knowledge,” while variables of moderate and significant knowledge were clubbed together into “moderate/significant knowledge.”
Precontinuing medical education knowledge and skills of the participants
In CME-1 (n = 27), 51.8% of the participants reported limited knowledge, whereas 48.2% perceived moderate/significant knowledge in their ability to work as a team leader or team member in management of patients with medical complications of SUD. In their ability to identify and manage opioid overdose, 62.9% of the participants reported limited, whereas only 37.1% reported moderate/significant knowledge. When asked about their perceived knowledge and skills for identifying and managing alcohol withdrawal seizures, 44.5% and 55.5% reported limited and moderate/significant knowledge, respectively. In the domain of their ability to educate peers regarding medical complications in patients with SUDs, 51.8% of the participants reported limited, whereas 48.2% reported moderate/significant knowledge.
In CME-2 (n = 42), 71.4% of the participants reported limited knowledge, whereas 28.6% reported moderate/significant knowledge in their ability to work as a team leader or team member in management of patients with medical complications of SUD. Similarly, most of the participants reported limited knowledge in terms of their perceived knowledge and skill to identify and correctly manage SUDs in the presence of HIV (78.6%), in the presence of hepatitis B (80.9%), ability to identify and manage chronic pain with comorbid SUD (78.5%), identify signs and symptoms of COPD (71.4%), and identify signs and symptoms of cardiomyopathy (76.3%). In their ability to educate peers regarding medical complications in patients with SUDs, 69% of the participants reported limited, whereas 31% reported moderate/significant knowledge.
Pre-CME objective knowledge (based on multiple-choice questionnaire) showed a mean score of 4.15 (SD: 1.59; range 1–7) for CME-1 (n = 61) and 3.98 (SD: 1.87; range 0–9) for CME-2 (n = 90), respectively.
Postcontinuing medical education knowledge and skills of the participants
In post-CME evaluation in CME-1 (n = 27), majority of the participants reported moderate/significant knowledge in domains of ability to work as a team leader or team member in management of patients with medical complications of SUD (70.4%), ability to identify and manage opioid overdose (81.5%), and identifying and managing alcohol withdrawal seizures correctly (81.5%). In the domain of their ability to educate peers regarding medical complications in patients with SUDs, 51.8% of the participants reported limited, whereas 48.2% reported moderate/significant knowledge.
In terms of post-CME perceived knowledge and skills in CME-2 (n = 42), 35.7% of the participants reported limited knowledge, whereas 64.3% reported moderate/significant knowledge in their ability to work as a team leader or team member in management of patients with medical complications of SUD. In their perceived knowledge and skill to identify and correctly manage SUDs in the presence of HIV, 26.2% of the participants reported limited, whereas 73.8% reported moderate/significant knowledge. When asked about perceived knowledge and skills to identify and manage SUDs in the presence of hepatitis B, 35.7% and 64.3% reported limited and moderate/significant knowledge, respectively. In the domain of their ability to identify and manage chronic pain with comorbid SUD, 38.1% of the participants reported limited, whereas 61.9% reported moderate/significant knowledge. In their ability to identify signs and symptoms of COPD, 23.8% of the participants reported limited, whereas 76.2% reported moderate/significant knowledge. In their ability to identify signs and symptoms of cardiomyopathy, 76.3% of the participants reported limited, whereas 23.7% reported moderate/significant knowledge. In their ability to educate peers regarding medical complications in patients with SUDs, 19% of the participants reported limited, whereas 81% reported moderate/significant knowledge.
Post-CME objective knowledge (based on multiple-choice questionnaire) showed a mean score of 5.41 (SD: 1.99) for CME-1 and 6.17 (SD: 1.75) for CME-2, respectively.
Comparison of perceived knowledge and skills pre- and postcontinuing medical education
As shown in [Table 3], in CME-1 (n = 27), there was a significant increase in the proportion of participants reporting moderate or significant knowledge in the post-CME assessment. The knowledge domains measured were as follows: ability to work as a team leader or team member in management of patients with medical complications of SUD (z = −3.252; P = 0.001), identify and correctly manage opioid overdose (z = −4.025; P < 0.001), identify and correctly manage alcohol withdrawal seizures (z = −3.368; P = 0.001), and educate peers regarding with medical complications of SUDs (z = −3.841; P < 0.001).
|Table 3: Comparison of perceived knowledge and skills pre- and postcontinuing medical education|
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The CME-2 (n = 42) too revealed similar results in the perceived knowledge [Table 3].
Comparison of objective knowledge pre- and postcontinuing medical education
For both the CMEs combined, the mean (SD) pre-CME score on the MCQs was 4.04 (1.75). The mean (SD) score after the CME was 5.87 (1.87). This increase in score was statistically significant (P < 0.001). Similar results were seen for individual CMEs as well [Table 4].
|Table 4: Comparison of objective knowledge pre- and postcontinuing medical education|
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Perceived quality of continuing medical education
As shown in [Table 5], more than half of the participants (of CME-1 and CME-2 combined) felt that the CME was excellent in terms of the practical value of material (60.3%), able to meet its stated objectives (60.3%), quality of instructions (58.8%), and organization of material (60.3%). None of the participants of the CME rated these quality parameters as poor.
| Discussion|| |
Our study suggests that CME through interactive lectures and problem-based learning of medical comorbidities in SUDs could effectively improve both the perceived (subjective) and objective knowledge of the participants, at least in the short term. Similar observations across two CMEs indicate robustness of our findings. Almost all the participants rated excellent or good, the quality of the CMEs in terms of practical usefulness, conforming to the stated learning objectives, the clarity of instruction, and the organization of material. These ratings indirectly suggest that the improvement of the acquired (and retained) knowledge was as a result of the sessions of the CMEs. The demographic and the clinical practice parameters of the participants, being similar in both the CMEs, indicate that we might be able to capture the target group of participants (psychiatrists).
Several reviews have been published on the effectiveness of CMEs for physicians.,,, These acknowledged both their methodological limitations and modest effectiveness in acquisition and retention of knowledge. However, the evidence of improvement in physicians' performance and patient outcome is understudied and relatively weak. Interactive sessions, use of multiple modes of teaching, content of CME designed for specific group of doctors from a single discipline, have been shown to moderate the effectiveness of CME on domains of knowledge and performanc. Similar to majority of the published literature, our study demonstrated improvement in subjectively and objectively measured acquisition and retention of knowledge at the end of the CME.
In our study, the preassessment showed that the participants had “very limited” or “some” knowledge of the medical comorbidities frequently associated with SUDs. In fact, the perceived “ability” to work with the patients with these medical disorders and to educate their peers was also found to be limited. These findings reflect the need for training on co-occurring medical and SUDs. More importantly, our study showed that CMEs might be able to address the unmet need. After attending CMEs, the significant improvement of the participants in the perceived abilities “to work in a team” and work with the peers was indicative of the fact that the CME could bring home the vital message of integrative and collaborative care.
We acknowledge the following limitations of our study: (1) affective and psychomotor domain was not assessed, and (2) although the overall response rate in our CMEs of nearly 65% is an acceptable figure, only 40% of the participants completed both the pre- and postassessment pro forma. (3) Although there was no significant difference of demographic and practice-related characteristics between those who completed only preassessment and those who completed both pre- and postassessments, the possibility of selection bias could not be ruled out, i.e., among all those who participated in CMEs, only those who might have perceived benefit from attending the CME program might have responded to both pre- and posttest questionnaire. (4) An observational and uncontrolled design with a relatively low response rate limited the generalizability of our findings. While the pre-post quasi-experimental design has been applied to examine the effectiveness of CMEs, this design is inadequate to comment on the efficacy of CME. (5) We did not assess the long-term effect of the CMEs on participants' performance, which are cumbersome but important. A prospective assessment of the participants could discern the change of practice and persistence of the “CME effect.”
In the future, the affective and psychomotor domain should be assessed in pre/posttest through case vignette-based methods. For this, a standardized objective structured clinical examination approach would be useful. For better response rate, the completion of pre- and posttest may be made mandatory for participation in CME; issuing of a participation certificate of CME may be made contingent on the completion of pre- and posttest assignment. Finally, the cohort could be followed up longitudinally to explore the effect of CME on the clinical usefulness and potential to change practice.
To the best of our knowledge, there is no published literature on the effectiveness of CMEs in addiction psychiatry. If the unmet training need of addiction psychiatry has to be met with the limited available resources, CMEs could be one of the modalities. The study showed that CME is a viable option for training of psychiatrists (or psychiatric trainees) through an interactive platform to address the unmet need regarding the knowledge and perceived ability to deal with physical comorbidities in SUDs.
| Conclusion|| |
We want to convey a couple of take-home messages. First, psychiatrists often lack the knowledge and perceived ability to deal with physical comorbidities in SUDs. Second, CME imparting practical knowledge and skills through an interactive platform is a viable option for training of psychiatrists (or psychiatric trainees) to address the unmet and under-recognized need.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]