Meeting #11

San Francisco, California

October 20 - 23, 2004



Present at the meeting were Drs. Schuckit (Director), Guschwan, Tapert (Associate Directors), DiMartini, Fireman, Sakai -- Senior Scholars (due to a last-minute emergency, Dr. Book was unable to attend), Brown (University of Wisconsin), Busch (Harvard Medical School), Hernandez-Avila (University of Connecticut), Sattar (Creighton University), Trocki (RSA/Alcohol Research Group), Sungwon Roh (a guest from Korea), and Marcy Gregg.



I. Wednesday, October 20th.

The meeting began Wednesday evening, October 20th, with a get together at the hotel. The group then walked to Crown Point Press for a demonstration of the creation of etchings, and enjoyed an informal dinner at Hawthorn Lane restaurant. Introductions were made all around, we had a chance to share our backgrounds, and an overview of the next day=s tasks was presented.



II. Thursday, October 21st.

Our group reconvened at the Pan Pacific Hotel at 8:00 a.m. More formal introductions were shared. New scholars were introduced, and the schedule for the upcoming days was discussed.

The more formal activities began with a demonstration by Dr. Schuckit of a 20-minute lecture focused on a specific but diverse audience. The purpose, reasons for structuring the lecture in a specific manner, and time frames were presented, after which the lecture was demonstrated. The presentation was then deconstructed to make several points regarding lectures, including the importance of fitting the material to the audience, the need to establish four major points around which the lecture flows, decisions regarding which elements of information are to be stressed, reasons behind the specific structure of slides, and issues related to the general approach of lecturing.

This was then followed with a two-hour presentation by Dr. Schuckit of “How to Give a Lecture.” As demonstrated on our Web site, the lecture reviewed each step in preparation (the major effort for any lecture), development of slides, presentation, handling of questions, and so on. A great deal of time was spent discussing how to review the literature and take notes, as well as the elements of organizing an outline using those notes.

In keeping with the traditions of AMSP, the group then had a working lunch focusing on career development issues. Topics included how to select research areas, problems with starting up research, balancing efforts required to keep one=s salary covered, assets and liabilities of committee work, and how to prioritize assignments and efforts on a day-to-day basis.

Lunch was followed with a presentation by Susan Tapert regarding PowerPoint. This is an overview of how to develop effective slides, and a demonstration of how these can work to the benefit of a lecture, without detracting from the delivery.

Marian Fireman, a second year scholar from the Oregon Health Sciences University, next presented an overview of her accomplishments during the prior six months. Regarding medical students, Dr. Fireman continues to be the clerkship director for psychiatry at OHSU. She is a member of the Medical Student Education Committee for the Department of Psychiatry, and of the Clinical Services Subcommittee of the Curriculum Committee of the School of Medicine. She has been writing and implementing objectives for the clerkship as recommended in the recent LCME site visit. Included in these objectives will be two relating specifically to the management of patients with alcohol and other substance use disorders. She also plans to add 1-2 lectures on alcohol and substance use disorders to the core curriculum for the psychiatry clerkship. A lecture on “Emergency Management” is in the process of being developed. Students rotating through psychiatry may elect a half-day ambulatory clinic, and she has recently added an elective with the geriatric addictions clinic in which she supervises one student. Another addictions clinic is also an option – that clinic recently expanded to accept two students per rotation, and both clinics have been well received by the students. She also continues to meet with 2-3 students per rotation for an informal interviewing seminar and discussion session. She will be co-director of a half-day required didactic given to all 3rd year medical students on Alcohol and Substance Use disorders, which is scheduled for March 2005. She recently finished reviewing the entire 4-year undergraduate medical curriculum at her school with regard to teaching on alcohol and other substance use disorders. She plans to write up her findings and present them to the chairman of the curriculum committee in November or December.

For residents, Dr. Fireman was recently appointed to the Residency Training Committee. Her focus there will be on both the didactic and clinical experiences in addiction psychiatry. She hopes to expand the Addiction Psychiatry core curriculum (of which she is director) from 3 to 6 months. She will also participate in the revision of the current third-year clinical rotation in addictions. She plans to continue interviewing residency applicants this year, and to participate in the VA consultation psychiatry seminar while also serving as a lecturer in the neurosciences seminar. She currently supervises a second-year resident in the outpatient clinic, a second-year resident for a half-day weekly experience in the transplant clinic and a second-year resident for a half-day a week in the geriatrics clinic. She supervises a fourth-year resident in the Hepatitis C clinic, and a fifth-year resident (geropsychiatry fellow) in the geriatric addictions clinic.

Regarding fellows, Dr. Fireman is a member of the Addictions Psychiatry Fellowship Training Committee and recently participated in a site visit for accreditation of the fellowship. She hopes to expand her role with the fellowship in the coming year.

Additional activities included her recent appointment to the Medical School Continuing Medical Education Advisory Committee; she continues as a representative from the Oregon Psychiatric Association to the Oregon Board of Medical Examiners; and was recently invited to lecture to county mental health workers on Psychiatric and Substance Use Disorders in Organ Transplantation. She was part of the faculty for the National VA Advanced Liver Disease Training Program in Las Vegas in September 2004 and lectured on “Psychiatric and Substance Use Disorders in Liver Transplantation.”

The day’s session ended with a focus on potential lecture topics for each of the first-year scholars. These were to be discussed among the first-year group, as well as with members of the second-year group, with the hope that final assignments of lecture topics will be arrived at the next day (Friday), with the goal of also having senior-scholar mentors selected by first-year scholars before the end of the meeting.

The day’s sessions adjourned at 2:30 p.m.



III. Friday, October 22nd.

Our group reconvened at 8:00 a.m. Marc and Marcy handed out several materials, including a review of activities the first-year scholars might consider for their goals in medical schools, and a discussion of the roles of second-year scholars. Marc then reviewed some of the major issues regarding lecture development, including the fact that the four main points are really learning objectives. Participants were reminded of the importance of being available for all conference calls, as well as the full duration of all meetings.

Dr. Schuckit then worked with the group establishing deadlines for lecture development for first-year scholars. This included the necessity of having a solid draft of the lecture outline to Marc by December 15, 2004, a finalized draft of the lecture with which he will work by January 15, 2005, and a completely final draft (along with slides and references) to Marc by February 15, 2005.

Joseph Sakai of the University of Colorado then presented his lecture on opioid substitution. It was an excellent lecture, stayed easily on time, and was highly effective. The lecture was used as an example of how to modify slides that are a bit too busy, as well as noting when an a reference to a study might be abbreviated on a slide (especially when data listed were taken directly from the study), as well as a discussion of lecture style.

The next topic was the report of accomplishments of Andrea DiMartini of the University of Pittsburgh. Dr. Martini began by listing direct teaching efforts. First, over the last six months she has instituted a “How to Give a Lecture” series for the fourth-year psychiatry residents and fellows. The first two weeks of the seminar she gave Marc Schuckit’s lecture on ”How To Give A Lecture” and Susan Tapert’s lecture on “PowerPoint.” With that foundation she is meeting with the residents weekly, and the group is working on developing their outlines and PowerPoint slides for their upcoming Grand Rounds presentations. She is also doing practice sessions with residents so they can rehearse their presentations in the auditorium prior to actually presenting them. Dr. DiMartini has been asked to make this a regular part of the residency training didactics. In addition, beginning this year the senior residents are required to do a scholarly project, so she is working with the residency training directors to develop a series of workshops on project development, and will try to recruit senior residents to do alcohol research for their senior project.

Dr. DiMartini developed and presented what has become a standard two-hour seminar for the Psychiatric Epidemiology graduate students on the epidemiology and diagnoses of substance use disorders. This deals, in part, with methodological aspects of research involving substance use and substance use disorders. This lecture has become a standard part of the Psychiatric Epidemiology Training program. She also designed and gives a lecture on “Practical Issues in Validity in Alcohol Research” to the Measurement in Clinical Research Statistics course on measurement (mostly physicians). This has become a standard lecture in that course. She is now giving as a standard lecture to the consultation-liaison psychiatry residents a lecture on the assessment of organ transplant patients that includes a significant component of substance use/abuse assessment and treatment referral. Andrea will be giving a lecture to the hepatology fellows in their pathophysiology course on screening for and assessing alcohol use problems/disorders after having identified a need for such training through her work with the hepatology fellows in the transplant clinic.

Her mentoring achievements include a Family Practice Resident who assists in the collection and analysis of research data on her research project. They met several times a week to discuss diagnostic, recruitment/retention, data collection, and data analysis issues. Last fall the resident designed and presented a poster on their data, and over the spring/summer they co-authored a manuscript (which will be published next month) on the psychiatric co-morbidity of patients with alcoholic liver disease, and another manuscript they wrote is under review. Andrea also mentored a graduate student doing a research project on alcohol research. Andrea taught and assisted the student in the recruitment of participants, collection and analysis of data, and the creation of an oral presentation. Andrea taught this student how to use PowerPoint and develop a research presentation, which was given at the completion of her project.

Dr. DiMartini’s accomplishments in the community include working with the Chief of Addiction Medicine Services to host an “Alcohol Screening Day,” and will perhaps dovetail this with her lecture on “How to Assess for Alcohol Use and Problems.” She is scheduled to give a lecture at the Academy of Psychosomatic Medicine meeting in a boards review course November 17, 2004 -- a third of the talk is on alcohol/substance use in transplant patients. Andrea will be co-authoring a review article for hepatologists who will be seeking specialty certification in transplant medicine. Her topic will be on addictions and psychiatric issues in transplant patients.

Regarding her research efforts, she presented a poster on her research at the June 2004 Research Society on Alcoholism annual meeting. She will be giving an oral presentation at the American Association for the Study of Liver Diseases (annual conference for hepatologists and liver transplant surgeons) about her research on alcohol and tobacco use following liver transplantation for alcoholic liver disease on November 2, 2004. In February 2004 she received funding for an R01that will investigate long-term alcohol use and medical outcomes in liver transplant recipients transplanted due to alcoholic liver disease. Over the past year of AMSP Andrea has published four articles on alcohol/substance use issues and one book chapter in which alcohol /substance use was a third of the chapter.

Carlos Hernandez-Avila of the University of Connecticut (a first-year scholar) next presented some of his plans for the upcoming six months at his medical school. He plans to increase his first-year medical student two-hour class dealing with substance use disorders from the current two hours to three hours, will work to increase his current one-hour lecture to third-year medical students as part of their clerkship from one hour to three hours, and plans to expand his work with a medical student Psychiatric Interest group (about 15 second- and third-year students). Furthermore, he hopes to increase the amount of teaching he is doing to psychiatric residents regarding substance use disorders as part of the second-year crash course, perhaps building upon the lectures already developed for AMSP by Katie McQueen and Joseph Sakai. Carlos hopes to establish a rotation for both medical students and residents on the inpatient detoxification/rehab unit, and plans to use an AMSP-type lecture on lecturing to enhance his teachings to residents in addiction psychiatry. Furthermore, he will evaluate required hours in substance use disorders for psychiatric residents and psychiatric fellows, and use this to expand his efforts.

Randall Brown of the University of Wisconsin next presented his goals as a first-year scholar. Over the next six months he hopes to begin a series of steps building upon the fact that he has recently become the Director of an elective for medical students dealing with substance use disorders. They currently visit 12-step programs, do role-playing regarding enhancing motivations, discuss a case, and do role-playing regarding nicotine dependence. The AMSP scholars had several suggestions of how these efforts could be expanded. Furthermore, Randy is developing a proposal for the Wisconsin Society of Addiction Medicine, with the hopes of presenting either a workshop or a plenary session regarding substance use disorders in family practice. An additional opportunity comes from the fact that Dr. Brown was recently appointed Co-Director (with Michael Fleming) of the Addiction Consult Service, and Randy hopes to involve medical students and residents, expand the number of consultations, and impact on other services across the hospital. Dr. Brown also has an active buprenorphine clinic in which he hopes to involve medical students and residents, and perhaps develop an elective. Finally, Randy hopes to become a member of the Residency Education Committee for his Family Practice Department, and is considering beginning a DOC program.



The next item on the agenda was a review of the Web site by Marcy Gregg and Susan Tapert. Briefly, between January 1, 2004 and October 18, 2004 we have had an average of about 14,000 hits per month, including close to 6,500 visits (where an individual accessed at least one page). Users of the AMSP Web site came from six continents, including 32 countries in Europe. The greatest number of hits has been for the Medical Consequences lecture, as well as the lectures on Pharmacology, Substance Use Disorders in Physicians, Substance Use Disorders and the Family, Spirituality, An Overview of Diagnosis and Treatment, and the list of recommended videos. Susan is now working on optimizing access to the site (a recent problem developed with Google), and is adding to the site an opportunity for users to send us a message regarding their experiences with the AMSP site, as well as suggestions they might have for the future.

Marian Fireman next presented her lecture on Hepatitis C. This was a fine presentation that was highly effective. The group used the excellent slides that had already been developed by Marian to demonstrate how some could be simplified and how the cadence of the types of materials presented slide by slide could be expanded.

The meeting ended at 2:15 p.m.

Friday evening the group reconvened in the lobby of the hotel and walked to an excellent restaurant (Ponzu) for a fine informal dinner.



IV. Saturday, October 23rd.

The meeting convened at 7:00 a.m. We began with the report of accomplishments by Joseph Sakai. First, Dr. Sakai has focused on increasing medical student education on substance use disorders at Colorado University Medical School. Last year he drafted a case study of a standardized patient that was designed to test students’ ability to screen for alcohol use problems in a general medical clinic. This standardized case was administered to all fourth-year students at CU Medical School this summer (fourth-year students who have completed psychiatric and internal medicine clerkships). Although students are taught to screen for substance problems by using the CAGE, the majority of students failed to ask these questions (questions not asked: “cut down” 33%, “annoyed or angry” 71%, “guilty about drinking” 57%, and “eye opener” 46%). This means that more than three quarters did not ask the full CAGE. The case was an elderly woman with alcohol dependence, with a number of clues to her alcohol use having been given to students (including laboratory values, intermittent hypertension, a family history of alcohol dependence, social withdrawal, recent accidents, etc.). Despite this, 16% of students did not even ask questions about use of alcohol or illicit substances.

Although a proposed “substance use disorders thread” to help focus on alcohol and drug dependence across the years was not accepted by the curriculum committee, the chair of Dr. Sakai’s department and the Vice Chair of Education have responded favorably to these efforts, and are concerned about the standardized patient results. They have asked Joe to incorporate the curriculum he created into the medical school curriculum through other means (Human Behavior, and the third-year psychiatry clerkship).

Dr. Sakai continues to teach in a number of courses for the psychiatric residents. This year he was invited to again give five lectures on substance use disorders to the current intern class, to lecture in the PGY-III Consultation Liaison course (“Alcohol Related Issues in CL Psychiatry”), to give a talk in Dr. Tom Crowley’s core Substance Use Disorders course, and to speak in the Addiction Fellowship Seminar. Joe also teaches in Dr. Crowley’s fourth-year medical student elective.

This was followed with a demonstration by Andrea DiMartini of her lecture entitled: AA Clinical Assessment of Alcohol Use.” This excellent lecture served as a baseline for the discussion of the importance of avoiding jargon when possible, establishing an optimum speed of delivery, and offered the opportunity of discussing how specific slides were originally developed and how they might be modified for another audience or a different timeframe. This interesting discussion led to an assignment for Dr. DiMartini to take on the challenge of modifying the 40-minute lecture (with approximately 30 slides) into a 10- to at most 15-minute lecture using no more than 15 slides. Dr. DiMartini enthusiastically agreed, promising to be available to deliver the new modified lecture within half an hour.



We next turned to the description of plans for the next six months by Alisa Busch. She will begin by surveying what has been done in her medical school (Harvard has five separate psychiatric departments). She will expand her participation in the Patient-Doctor course, hoping to increase the number of students (she currently has access to approximately ten, but hopes to expand the introduction of substance use disorders to the full 120 students). Alisa will also take advantage of her experience in health-care policy by discussing the possibility of developing a lecture on substance use disorders focusing on health-care policy for delivery to medical students. She will consider proposing on an elective on substance use disorders, and it was also suggested that she look into the possibility of developing a DOC course. Alisa will re-evaluate the guidelines for development of programs at medical schools, and consider whether additional goals might be appropriate.

Andrea DiMartini then delivered a superb lecture as a ten-minute version of her original presentation. Her work showed how the four major points of a lecture can still be emphasized even if only 25% of the time is allotted. She also demonstrated how original slides could be very quickly modified, and the manner in which one can build a lecture around the four key slides.

Next, Pirzada Sattar discussed his plans for the next six months at Creighton University. These included reviewing the current set of activities for medical students at his University, doubling the current one-hour lecture on AAddictions,@ attempting to establish a mandatory rotation on substance use disorders for medical students, using the AMSP Website-based materials to offer an elective on alcohol and drug dependence, and attempt to develop informal luncheon meetings on substance use disorders topics. In addition, he hopes to schedule an alcohol screening day for medical students at his University.

Regarding resident education, he plans to continue to participate in the Residency Training Committee, push to increase the amount of education on substance use disorders for residents, develop an addictions journal club, look into the possibility of an addictions fellowship, and expand his work with the Addictions Training Scale. He is hoping to be a very active participant in several committees on resident education. At the same time, Dr. Sattar will also enhance his outreach to primary care residents regarding lectures on substance use disorders, as well as the potential of an elective.



The group next turned to discuss the topics selected by the first-year scholars, as well as their assignment to a second-year scholar. Dr. Randall Brown will develop a lecture on benzodiazepine long-term use, misuse, abuse, and dependence; he will work with both Drs. Sakai and Book. Dr. Carlos Hernandez-Avila will develop a lecture on alcohol withdrawal, also working with Drs. Book and Sakai. Dr. Pirzada Sattar will develop a lecture on non-pharmacological treatments of substance use disorders. Dr. Schuckit used this as an example, and demonstrated the types of materials he might develop, giving some guidance regarding the literature review that will be required. His senior scholar will be either Dr. DiMartini or Dr. Fireman. Finally, Dr. Alisa Busch selected the topic focusing on comparisons of efficacy and approaches in the treatment of substance use disorders versus other chronic relapsing conditions such as hypertension and diabetes. She will work with senior scholar, Dr. DiMartini for this topic.

The next order of business was to discuss the Spring meeting place and time. We are currently scheduled to begin at 6:00 p.m. on Wednesday, March 30th in New York. Dr. Guschwan will work with Marcy and Marc in taking the lead to organize the meeting. The participants were reminded of the importance of the dinners on Wednesday and Friday nights (of course, spouses are invited), and the fact that it is essential that they participate completely in the meeting by arriving no later than 6:00 p.m. on Wednesday, March 30th, and leaving no sooner than noon on Saturday, April 2nd.

A time for the next conference call was also discussed. Marcy will work with the group, but the best time appears to be Thursdays at 11:45 a.m. or noon San Diego time (2:45 or 3:00 p.m. East Coast time).

While the meeting officially ended at 11:00 a.m., most of the fellows were available until 11:30. This time was used for a discussion of additional career development issues including time management, rules in establishing the possibility of promotion, the importance of authorship position on a paper, the lack of meaning regarding who is the Acorresponding author,@ and promotion in non-research tracks.

Marc A. Schuckit, M.D.

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