New addictions training prepares residents to treat patients with confidence

Working with patients who are struggling with substance abuse is a complex undertaking that can be further complicated by a wide-range of comorbidities and social factors. Treating addiction can be intimidating for physicians early in their careers, and it was commonly identified as a challenge by graduates of the Department of Psychiatry’s residence program.

“There was a strong feeling among residents that addictions training was inadequate, and that led to a lack of confidence,” says Dr. Peter Voore, “We knew that, to improve residents’ confidence, we had to increase the skills and knowledge we were providing them with, so that they’d leave residency feeling qualified and capable.”

Voore, an Associate Professor in the Department of Psychiatry and Medical Director, Acute Care Program at CAMH, was appointed chair of a new working group that set out to address these issues by designing new addictions rotations for psychiatry residents. The group began meeting in summer 2018. It was a cross-hospital collaboration that incorporated resident input to ensure a full picture of patients’ and residents’ needs.

The new rotations were designed according to the Competency by Design (CBD) program and provide residents with hands-on experiences in a variety of settings.

Previously, residents were provided with one month of addictions training during PGY1, and a part-time addictions rotation in PGY4. Under the new program, residents have a two-month rotation in PGY2 and another 2 month rotation in PGY4, providing them with substantial experience working directly with patients.

The rotations are based at CAMH and St. Michael’s Hospital, which both treat large, diverse populations of patients. At CAMH, residents work in the centre’s medical withdrawal clinic, and the Concurrent Addictions Inpatient Treatment Service (CAIT) inpatient clinic. They spend three days a week working with addictions patients who have concurrent mental health conditions or trauma. They also spend one day a week at CAMH’s outpatient clinic, working with psychiatrists and addiction medicine doctors.

At St. Michael's Hospital, the psychiatry residents do a two month intensive block on the inpatient consult service as a part of a team with addiction fellows, as well as residents in family medicine, anesthesia, internal medicine and pain. They work with patients with high levels of medical comorbidity and low levels of motivation for various addiction medicine treatment. This includes managing complicated alcohol withdrawal, using mental health act forms for people with life-threatening medical conditions and substance use issues, providing a “safe supply” of opioids for people who inject drugs to help them complete their medical treatment, and engaging with patients to start them on opiate agonist treatment.

The new program will meet the Royal College’s minimum requirement for addiction medicine training for the first time. Additionally, U of T residents will also have the opportunity to build competencies that will count towards earning the Royal College new Areas of Focused Competence (AFC) diploma in addiction medicine.

The first PGY2 rotation took place in July 2019 and so far, the feedback is positive.

“Residents are pleased with the exposure they’re getting, the real-life experience with patients and the supervision,” says Voore, “We’re providing residents with the experience they need to feel prepared to practice in all settings. That, in turn, will allows them to work with their patients more effectively and help alleviate the suffering caused by addiction.”