What you need to know
Family doctors in Canada are often the first point of access to health care for people with opioid use disorders (OUD). Those who receive OUD treatment from their family doctor often have better health outcomes. Researchers reviewed curriculum related to the treatment of OUD for family medicine trainees at University of Toronto (UofT) teaching sites. They also interviewed eight recent UofT family medicine graduates about their level of comfort in treating OUD. Of 11 teaching sites that responded, three had mandatory clinical rotations in addictions, eight had no mandatory substance use rotations, and four did not respond. Four reported no formal teaching on addiction. The seven sites that offered formal teaching reported about one to five hours of formal teaching per year. Three interview participants said they had extra training after they completed their family medicine residency. One received emergency medicine training, another received addictions training, and the third did not disclose the area of additional training. The researchers describe the two overarching themes from their thematic analysis of graduate interviews as, “the structural marginalization of people with OUD and the invisibility of OUD within family practice.”
What is this research about?
Family doctors are the first point of access to health care for people with opioid use disorder (OUD). People with OUD who receive OAT from a family doctor are also more likely to stay on it, avoid unregulated opioids, and have higher satisfaction with treatment. Early-career family doctors may be more willing to treat OUD. One study found that about a third of US-based medical residents who received buprenorphine training continued to prescribe it.
Limited teaching and training have been found to perpetuate the stigma around caring for patients with substance use disorders. In addition, many early career family doctors say they feel unprepared to prescribe buprenorphine, while some do not prescribe the life-saving treatment at all. No Canadian studies have looked at the impact of medical training on the readiness to offer OAT among recent family medicine residency graduates.
What did the researchers do?
Researchers conducted an environmental scan of the medical school curriculum at several UofT teaching sites and qualitative interviews with recent family medicine graduates.
For the environmental scan, they contacted program directors and chief residents at all 15 UofT teaching sites using a standardized email. The email asked about any mandatory addiction rotations, with details about formalized curriculum related to OUD, buprenorphine, and/or methadone.
The interviews used an open-ended, semi-structured questionnaire, which asked about the family medicine graduates’ perceived learning needs related to mental health and addiction. The researchers also conducted a thematic analysis of interview responses.
What did the researchers find?
Environmental Scan Findings
Four teaching sites did not respond. Of the 11 chiefs and/or program directors who responded to the email questions, three had mandatory clinical rotations in addictions. One offered a two-week rotation in the first year of residency, one included four half-days in a rapid access addiction medicine clinic during a psychiatry rotation, and one included two half-days during a mental health rotation. Eight sites reported no mandatory substance use rotations.
In terms of formal education in addictions, four sites had no formal teaching during the weekly academic half-days. The seven sites that offered formal teaching provided about one to five hours per year of formal teaching.
The majority of teaching was done by family physicians with enhanced skills training in addiction medicine. Some teaching was done by family medicine faculty without enhanced skills training. In one instance, an emergency medicine physician delivered this content.
Graduate Interview Findings
The researchers interviewed four female and four male graduates of family medicine at UofT (29-31 years old).
Three participants said they had extra training after they completed their family medicine residency. One received emergency medicine training, another received addictions training, and another did not disclose the area of additional training.
Thematic analysis of the interviews highlighted two overarching themes:
- The educational environment or curricula within family medicine training reinforced the marginalization of people with OUD.
- Clients with OUD or treatment of OUD are not seen as a family medicine problem.
The researchers concluded that there is significant variation in training experiences related to OUD. They noted that, as a result, family medicine graduates are not ready to treat patients with OUD, including providing treatments like buprenorphine. They write that strategies to standardize clinical exposure and teaching in OUD across UofT sites are needed.
Limitations of the research
The authors identified several limitations to their study that should be considered when interpreting the results. For example, the study took place at a single university, so it is not possible to generalize the findings to other postgraduate programs in Canada.
The researchers also pointed out that the number of graduates who participated in the interviews was small. Still, they noted their analysis reached the point where they fully understood participants’ perspectives and where no further dimensions, nuances, or insights could be found. In addition, the study participants may have had a special interest in addiction, and individuals who do not have this special interest may have provided different types of responses.
How can you use this research?
This study provides insights that may be of use to institutions looking to standardize and improve the postgraduate family medicine curriculum and to improve priority topics and key features as they relate to OUD.
About the researchers
Bassi, J,1 Ramdawar, EA2,3,4,5 Selby, P,2,3,6,7,8; Stolarski, K,6 Wyman, J1,2 Lazare, K,2 Bozinoff, N1,2,6
- Division of Addiction Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- The Wilson Centre, University Health Network and Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Addictions Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- INTREPID Lab (formerly Nicotine Dependence Service), Centre for Addiction and Mental Health, Toronto, Ontario, Canada