What we know about ourselves: changing attitudes about treating patients with substance use disorders.

Patients with substance use disorders (SUD) are prevalent in most schools, hospitals, emergency departments, and in the criminal justice system. (1) Society has come more and more to view substance abuse and dependence as an illness and to implement programs that help people recover and lead productive lives. Treatment of SUD has many shortcomings including limited evidence-based practice parameters (2) and the typical relapsing and remitting course of this condition.

Lindberg et al (3) discusses the changing attitude of physicians toward caring for patients with substance abuse disorders from the beginning of their training to the time they finish their residencies. Understanding the dynamics of our professional interaction with these individuals plays a crucial role in increasing awareness of our own shortcomings. In this study, positive as well as negative attitudes of medical students and physicians-in-training toward caring for patients with substance abuse disorders are analyzed. Positive aspects, which remain stable during the training years, are the belief that professionals with SUD should be allowed continued employment upon remission, that patients with SUD can "recuperate" and lead productive lives, and that the physicians can learn from their patients about medical and social issues. Contrasting this is the finding, with potential negative effects, that medical students and house officers are confident that their training is adequate for treating individuals afflicted with SUD. However, these trainees increasingly believe that SUD patients abuse the available resources and detract care for other patients. Furthermore, the satisfaction in caring for these patients diminished over the years.

Another study (4) reported that resident and faculty satisfaction in caring for patients with SUD was less than the satisfaction in caring for patients with another medical condition (hypertension). It may be that the satisfaction in treating SUD patients reaches a low level at the end of training and never improves through our careers.

We can hypothesize several reasons for the finding presented in this paper. For example, the overwhelming workload for physicians-in-training leads to limited interaction time with patients. Another reason can be a learned feeling of helplessness, that nothing we do will improve our patient's condition. We are influenced throughout our careers by beliefs formed before (eg, relationship patterns and interpersonal interactions) and during medical school (eg, beneficence principle). These beliefs are modified by our experiences that often these patients continue to relapse despite our best efforts to stabilize and offer proper follow up. We may start seeing them as "draining the hospital resources" and "preventing other patients from receiving prompt care." This may lead to value judgments of the patients, such as having character flaws.

Interpersonal relations with such patients are important. At the first encounter, the physician may experience empathy toward the patient. This leads to a desire to help, to rescue the patient from his or her situation. As the patients continue to present to the emergency department, the physician may learn hopelessness (eg, "he/she is never going to get better") and start blaming the patient. Therefore, it is important to have appropriate knowledge regarding the course of the illness and to model accordingly our expectations. Once a patient obtains a diagnosis of substance dependence, (5) even if they are successfully treated and have not been using for years, the rate of relapse is high.

It is also useful to understand the patient perspective. They present to our service as a result of stressors such as sadness, pain, cold or hot weather, fear, injuries, intoxication, or withdrawal symptoms. It is common to report to the emergency department referred by law enforcement agencies, ambulance, or family or friends. As their relations with others are often strained, they may perceive us as their last resort.

Gerace (6) showed that with training, confidence and optimism in caring for patients with SUD increases. This suggests that it is possible, through specific interventions, to model some of our beliefs which can ultimately improve patient care and prognosis.

References

1. Tomas JM, Kozel NJ. National substance abuse epidemiology initiatives in the United States: what works for what. J Addict Dis 1991;11:5-21.

2. Pentz MA. Evidence-based prevention: characteristics, impact, and future direction. J Psychoactive Drugs May 2003;35 (Suppl 1):143-152.

3. Lindberg M, Vergara C, Wild-Wesley R, et al. Physicians-in-training attitudes toward caring for and working with patients with alcohol and drug abuse diagnoses. South Med J 2006;99:28-35.

4. Saitz R, Friedmann PD, Sullivan LM, et al. Professional satisfaction experienced when caring for substance-abusing patients: faculty and resident physician perspectives. J Gen Intern Med May 2002;17:373-376.

5. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association; 2000.

6. Gerace LM, Hughes TL, Spunt J. Improving nurses' responses toward substance-misusing patients: a clinical evaluation project. Arch Psychiatr Nurs 1995;9:286-294.

Robert G. Bota, MD

From the Department of Psychiatry, University of Missouri, Kansas City, MO; Middle Flint Behavioral Health Center and Sumter Regional Hospital, Americus, GA.

Reprint requests to Robert G. Bota, MD, 415 North Jackson Street, Americus, GA 31709. Email: [e-mail]

Accepted October 25, 2005.