Category: Change

Four years post doctorate

Being a senior postdoc brings many opportunities. I wrote about them in my blog last year. Now, I’d like to revisit them, see what’s new and what has changed.
CREDIT: Hal Mayforth
 
 
 Three years post doctorate, I wanted:
 
-To keep writing a lot.
In the third year post doctorate, I wrote a lot about these topics:
 How doctors sweat to discover traditions of the first nations; What to look for in mentoring? Finding the Evidence for Talking Therapies; My First Week in the Addiction Research Paradise; How to go about getting a postdoc position?; How mentoring can help transitions in academia; The best time for writing; Postdoctoral Fellowship Awards for Irish researchers; How to addess a Training Gap through Addiction Research Education for Medical Students; Mobility is part of research job description;Different styles of research supervision; How attractive are you for postgraduate students? How to build research leaders and supervisors; Working and holidays; The Annual Symposium of the Society for the Study of Addiction 2013; Re-entry shock; Saying bye slowly makes parting easier; A decade in the addictions field.
 
-To stay true to myself.
This was difficult. At times, I honestly have not been honest. I’ll keep at it.
 
-To reach a position of independence by:
 
a) conducting a randomized controlled trial
The pilot trial is finished. First, we wrote down our plan, a cook book for making this trial. Second, we developed and pilot tested a workshop which was later used as part of the experimental intervention. The controls received the intervention with a delay. Third, we measured the status at baselineto set up our starting point. Watch this space for more about the trial results.
 
b) supervising work of junior investigators.
My junior colleagues from the pilot trial helped me to learn how to be a better team player.
 
-To pass the accumulated knowledge and skills on other:
 
c) Doctors and helping professions, by helping them become more competent and confident in addiction medicine research
d) Medical students, by helping them discover and master addiction medicine research.
I had the honour to co-supervise a group of three gifted postdocs and several medical students. Two of them moved for work or study to UK. I’m grateful for the learning that workingwith them brought me.
 
-To maintain a happy work-life balance.
At the time when I wrote that, I realised that I took on too much. In the past year, life and family brought new challenges and I needed to split my time between them. Integrating my scientist and artist careers was another chance to learn the balancing act.
 
In the fourth, post-doctoral year, I’ve extended my research to addiction medicine education. This is new to me. This expansion challenged my time management skills. I wish to be able to see which of my ideas and projects need more attention and which should be put to sleep.

Resolution 2015

“I write one page of masterpiece to ninety-one pages of sh…t, I try to put the sh…t in the wastebasket.” Hemingway

 

Eighty years after Hemingway confided to F. Scott Fitzgerald 1934, I join his self-criticism.



Ernest Hemingway Collection. John F. Kennedy Presidential Library and Museum, Boston.
photocredit: http://goinswriter.com/write-drunk/
In 2014, I’ve published my 100thblog post. I wrote one masterpiece to ninety-nine posts of sh…t. I tried to put the sh…t posts in the wastebasket, but the lure of the magical 100thmilestone was stronger. The number of my new posts doubled every year – starting with 14 in 2012, through 28 in 2013, to 58 in 2014. Keeping up with this trend will be a challenge in 2015.

While looking for Hemingway’s photo for this post, I found two other parallels between his life, work and my passions. First, he had an alcohol use disorder which led him to his tragic end. Mental health and substance use disorders have been the subject for most of my posts this year. If you identify as a woman, don’t drink more than 2-3 standard drinks per day. If you identify as a man, don’t drink more than 3-4 standarddrinks per day. It doesn’t matter that it’s Christmas. These are recommended low-risk drinking limits. Second, this fantastic software, named after Hemingway, can improve your writing: http://www.hemingwayapp.com/As its creators write: “Hemingway App makes your writing bold and clear. Hemingway highlights long, complex sentences and common errors.”

I want to keep writing a lot, but I also want to write for new publications, websites and channels.

Readers of my blog will see less premieres and more re-publications. I will re-posts my texts from other websites that I (will) support to keep the writing ball rolling.

With this, I’d like to thank you for reading. I wish you a productive 2015.

Keep writing a lot!

Patient-Related Drinking and Alcohol Counselling: Do Doctors Own Lifestyle Habits Matter?

The medical degree isn’t a vaccine against addiction.​ ​​“If you don’t drink as much as your GP, you don’t drink too much,” an old saying goes. When it comes to doctors’ own lifestyle habits and patient-related alcohol counselling, the science remains silent.

Personal Experience
Surveys of physicians’ attitudes towards drugs or drinking are multitude. They are relatively easy to do – doctors answer them by circling numbers or ticking the boxes in research questionnaires. While sometimes it’s easy to figure out the purpose of the survey and adjust one’s answers accordingly, other times the survey doesn’t give clues about its underlying goals.
Photocredit: wisequacks.org
​A Boston surveyasked over a hundred family doctors whether they knew someone (other than a patient) with an alcohol or drug problem. Up to 85% knew someone with these problems and about a third of them said this person was “family, a close friend or themselves.” Compared to the rest of the survey, they were more confident in asking patients about alcohol and advising on low-risk drinking. This positive effect did not translate to the other parts of their job, such as “perceived responsibility, attitudes, professional satisfaction, and practices”, though.
When faced with a “human face” of addiction, some medical doctors change their preconceptions:

“I found the workshop really eye opening. It changed my preconceptions of what I thought a ‘drunk Doctor’ would be like; when we were all sat around the table I was wondering to myself when the Doctor would be coming to speak to us and why he wasn’t there already, so I was taken by surprise when it turned out he was sitting right opposite me! I think that shows that this really is an issue that needs to be put in front of medical students as most like me will only have come into contact with alcoholism through seeing patients on wards, or seeing people in the street.”

The Example comments made by students who attended an addictions workshop were taken from http://www.sgul.ac.uk/research/projects/icdp/pdf/smugprojectreport.pdf  The doctor was a member of the Sick Doctors Trust http://sick-doctors-trust.co.uk/
The measurement problem
Two measurement problems hinder research on this topic. How to measure doctors’ drinking? How to measure the alcohol treatment they provide to patients with addiction?
Objective measures of alcohol consumption would be best. The measures we normally use are unreliable – Breathalyzers or ETG (Ethyl Glucuronide) tests. Apart from being perhaps somewhat intrusive for docs, they it pick up recent drinking only. Similar to other alcohol research, we would have to rely on what the doctors tell us.
Actual measures of practice are less worrying than objective measures of drinking. Again, measuring success of doctors’ approach by the number of abstaining patients is extremely difficult. Our best shots are proxy measures, such as number of prescribed medications or number of referrals to specialists. Although audits of doctors’ practice have been found to underestimate the actual care delivered by doctors, the Self-reports of practice seem to inflate the figures.
Other lifestyle habits
A previously published blog post and an article in the Irish Psychologist described two studies that illustrated how doctors’ lifestyle habits matter and how their ambivalence can be boosted. Research at the University of Michigan, cardiovascular centre demonstrated how doctors’ confidence in their ability to advise patients on diet and exercise correspond with their own personal health and fitness levels. Maybe lifestyle habits influence health care (in one paper) for a different issue (diet/exercise), but does that relate in some way to alcohol?
Another team supervised by Hettema and Sorensen used Motivational enhancement therapy (MET) to help medical trainees to resolve their ambivalence around managing alcohol and drug problems. They’ve put a group of nine medical residents through a brief MET therapy before they learned more about alcohol consulting and advice-giving. Five weeks later, their consulting and advice-giving went up, but due to the small numbers, the researchers called for caution with interpretation of their results.
 
No one is immune from addiction. While we know that doctors do get it too, we see little, if any, literature that specifically supports a statistically significant association between physician drinking and physician screening or counselling. In another words, we don’t know whether their own drinking or drug taking influences how they treat addictions. Can you find a paper?

Take precautions: improve or improv-ise?

“A ship is safe in harbor, but that’s not what ships are for.” ― William G.T. Shedd

How much uncertainty can you live with? A lot, at least I thought so until I started a new course in improvisation. Improv is a bit like acting without a script. Scary? Here’s how this new experience helped me to lighten up my life.

Uncertainty is the only certainty there is, and knowing how to live with insecurity is the only security.” – J. A. Paulos

Before the improv course, precaution was my modus operandi. I was prepared, over-prepared and hyper-prepared for anything and everything. Like many other people, over-preparation was my way of coping with the uncertainty of life. I learned that careful preparation improved my performance and outcomes. This improvement, however, had limits and I couldn’t do better regardless of how much time I spent with preparation.

Life is what happens to you while you’re busy making other plans” – J Lennon

Figure 1 Neil Curran (R) photo credit: lowerthetone.com
 The Improv course with NeilCurran re-defined perfection for me. Over-preparation can often lead to a stilted impression. As if the spirit of doing things evaporated the moment you get in front of your audience, committee, boss or panel – you replace the addressee. Furthermore, you can only prepare for things you can foresee. But there are always unforeseen events. Improvisation helps you react to those challenges. Like any other art, it gives you the freedom of being here and now and reacting to whatever comes your way. It’s a way of being. An other paradigm. Some critics may say improvisation is lousiness, lack of knowledge or skill, neglect or laziness – something that should be avoided. The opposite is truth; improv skills allow you to respond when you run out of your prepared responses – to transcend yourself.

Improv and medical profession

The role of improv in medical profession is bigger than you might think. Although there are strict procedures and guidelines for most medical procedures, there’s still a lot that we don’t know and therefore – cannot regulate. Clinical intuition is invaluable in unregulated or over-regulated situations. Similar to improv, intuiting is reacting to the situation based on previous knowledge, experience and trust in the process. Atul Gawande, in his book The Checklist Manifesto, advocates using checklist to make sure the basics are done. This creates room for clinical wisdom and intuition to deal with unforeseen events. Instead of making rigid orders to doctors and thereby stripping their responsibility and clinical judgment away, the Checklist helps people make sure they do the basic and essential things, leaving enough space for intuition and … you’ve guessed it – for improvisation.

Can GPs help problem drinkers who also use other drugs? Article in the Forum magazine

The Forum magazine is the official journal of the Irish College of General Practitioners ICGP. Published monthly by MedMedia since 1991, it is Ireland’s premier journal of medical education.

In January, the journal published a clinical review by McGowan et al (2014)1 which provides a reader-friendly summary of the evidence on the brief interventions in primary care. We commend the authors for that but also wish to highlight the additional challenges involved in implementing brief interventions for at-risk groups including people who also use other drugs, in economically challenging times.

In Ireland, we rank first in the use of heroin in Europe2. With more than 3000 patients attending general practice for methadone treatment, Ireland has a well-established and internationally recognised good example of primary-care based opioid substitution programme 3. Internationally, excessive drinking by patients recovering from drug dependence, is often overlooked and underestimated4. In Ireland, a national survey of primary-care based methadone treatment found 35% prevalence of ‘problem drinking’5. Although effective brief interventions for the general population are available, when it comes to other drugs – we’re still guessing.

To explore the scientific evidence on brief interventions for people who also use other drugs, we conducted a Cochrane systematic review6. Drinking in methadone treatment is probably as old as the methadone treatment itself, but only four clinical trials evaluated effectiveness of interventions to tackle it. Those trials were so different, that we couldn’t pool their results together and come up with a definitive answer. Since the literature couldn’t give us a conclusive answer, we asked patients and their GPs what they think of alcohol interventions in methadone treatment. Surprisingly, the patients didn’t oppose being asked about drinking and welcomed it as a sign of GP caring about them as whole persons7. GPs reported issues that were similar to other countries – time, lack of specialist staff and training8. With increasing workload demands, time is certainly a big issue for GPs, although clear guidance and training on delivering effective ‘brief’ interventions for problem alcohol use can help GPs address this issue within the constraints of a ten-minute consultation.
The information from the Cochrane review and qualitative interviews helped us to formulate clinical guidelines for primary care 9. The guideline development group recommended that all patients in methadone treatment are screened for alcohol annually, that thresholds for screening and referral are lowered for this patient group and that the screening process is more proactive. No matter how good such guidelines are, they never implement themselves10. Structural, organisational and individual barriers hinder the process of implementing innovation in general practice – similar to other clinical areas 11.
Given these barriers, our group developed a ‘complex intervention’ to support care of problem alcohol and drug users 12, consisting of a brief alcohol intervention for people who also use other drugs, coupled with additional practice support with care and referral. The next step in developing the complex intervention is its testing in a controlled feasibility study 13. The study, ‘Are Psychosocial INTerventions Effective for Problem Alcohol Use among Problem Drug Users’ (the PINTA study) involves 16 practices in Ireland’s Midwest and Eastern regions14. The focus of this study is to evaluate the impact of psychology based treatments as opposed to the approach of medicating patients dealing with drug and alcohol addiction. There is a significant knowledge gap in this area internationally and we hope this study will help practitioners in Ireland assist their patients to deal with this issue 15… Read more at www.icgp.ie
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