Addressing Alcohol-Impaired Driving: Continuing Medical Education for Practitioners

Continuing Medical Education for Practitioners:

The University of Washington Continuing Medical Education (CME) office is the primary source of continuing medical education programs for clinicians in the Pacific Northwest. The UW School of Medicine also operates an on-line newsletter for physicians in the region. CME programs were advertised through this route, and specific information about this project’s activities was included on a regular basis. We accomplished the following:

Contacted the heads of CME programs for the WAMI states to offer them our training package which included physician workshops of various lengths of training time. We found that the heads of CMEs in the Washington, Alaska, Montana and Idaho region are very familiar with those topics that attract physicians to CME lectures and those topics that do not yield good turnouts. Unfortunately, they told us that our topic of brief alcohol interventions was a difficult one to promote. However, we were able to schedule and deliver numerous free physician CME training workshops. These workshops followed the same format as that described above for training resident physicians. These training sessions are summarized in Table 6 below.

Length (hrs.)	Group	Participants
1.5	General internal medicine (GIM) residents	10
2.0	Rehabilitation unit nurses	55
1.5	GIM residents	6
2.0	Valley family medicine residents	8
1.5	Family medicine residents	8
0.75	1 x 1 detailing with MD *	1
0.25	1 x 1 detailing with MD *	1
2.0	Family medicine residents	5
0.5	GIM residents	4
0.5	GIM residents	5
1.5	Family Medicine residents	6
0.5	GIM residents	5
0.75	Family medicine residents, Tacoma, WA	20
0.5	GIM residents	5
1.0	Neurology residents	15
0.5	GIM residents	5
0.5	1 x 1 detailing with MD *	1
0.5	1 x 1 detailing with MD *	0
0.5	1 x 1 detailing with MD *	1
2.0	UW Medical students	9
2.0	Family medicine residents, Tacoma	6
1.25	Family medicine residents, Tacoma	1
1.25	Family medicine residents, Tacoma	6
0.5	1 x 1 detailing with MD*	1
1.5	GIM residents	9
1.0	Trauma residents and surgeons	9
1.5	Surgery Clerkship student lecture	20
.75	Family medicine residents, Tacoma	20
1.5	Surgery Clerkship student lecture	20
.5	1 x 1 detailing with MD*	1
1.0	Valley Hospital physicians *	30
2.0	Psychiatry clerkship students	20
2.5	Family medicine residents, Tacoma	20
1.5	Surgery Clerkship medical students	20
1.5	GIM residents	12
1.0	Obstetrics and Gynecology physicians & residents *	25
1.0	Obstetrics and Gynecology residents	8
3.0	GIM residents, Spokane, WA	30
3.0	Nursing students	20
1.0	Family medicine residents, Tacoma	6
1.5	1 x 1 detailing with MD	23
1.0	Family medicine residents	25
1.5	Surgery Clerkship students	20
1.0	Emergency Medicine physicians *	30
2.0	Public Health nurses	12
1.0	Boise, ID physicians *	22
1.0	Boise, ID physicians *	56
2.0	Family medicine residents	15
.5	Family Medicine residents	20
1.5	Surgery Clerkship student lecture	20
?	WA St. Obstetrics conference *	60
.75	GIM residents	20
1.25	Public Health nurses	85
2.0	Medicine residents, Yakima, Seattle	20
2.0	American College of Physicians annual conference, Seattle *	50
2.0	Family medicine residents, Boise, ID	50
1.5	Surgery Clerkship student lecture	20
2.0	Family medicine residents	25
5.0	WA State conference of School nurses	75
0.5	WA State conference of Trauma nurses	100
2.0	UW Psychiatry clerkship students	20
2.0	UW Psychiatry clerkship students	20
2.0	UW Psychiatry clerkship students	20
2.0	UW Psychiatry clerkship students	20
1.0	Family Medicine residents, Tacoma, WA	20
1.0	Family Medicine residents, Tacoma, WA	20
2.5	Family medicine residents	8
2.0	Family medicine residents	12
Note: * indicates CME training for practicing physicians All training in Seattle unless indicated otherwise

We mailed out information to all primary care physicians in King County, Washington, to offer them free training 1 x 1 academic in their own offices in alcohol screening and brief intervention. This unfortunately produced only a few requests for training. We believe this reflects the busy practices of physicians in the county and the results of the health care financing crisis.
Because of this low response rate, we surveyed a random sample of 400 King County primary care physicians, investigating their current screening and brief intervention practices. We have come to believe that screening for alcohol abuse must occur more automatically, without requiring as much action on the part of physicians. The literature would also suggest that accurate assessment of alcohol abuse requires a more formal method of screening than just asking about quantity and frequency of alcohol use. One way to accomplish this is to use a written questionnaire. This can most easily be accomplished by adding questions on alcohol use to a periodic health history questionnaire.

The results of our survey of King County physicians are shown in Table 7 and are as follows:

There was a 67% return rate to the questionnaire, yielding 280 usable questionnaires from physicians.
Of 280 respondents answering question #1, 148 (53%) indicated that they used a self-administered questionnaire that included questions about drinking.
Of these 148 physicians, 110 (74%) used only questions about quantity and/or frequency, 23 (16%) used some combination of quantity/frequency and CAGE questions, and 11 (7%) used CAGE only.
Of 125 physicians who reported in question #1 that they did not use a self-administered questionnaire to screen for alcohol problems, 104 (83%) reported that they would be willing to add standardized screening questions to their screening protocols.
Nearly all physicians (n=264, 95%) reported that when concerned about patients’ drinking, they took action including various combinations of charting in the medical record, discussing concerns with patients, and referring patients for specialty care.
However, only 123 (44%) physicians charted their concerns in the medical record. Thus, the medical record may serve as an inaccurate measure of the screening and counseling practices of primary care physicians.

Table 7:
Survey Results of Internal and Family Medicine Physicians

Survey Questions:		Internists n (%)	Family Physicians n (%)	Total Responses n (%)
1.	Do you give new patients in your practice a self-administered questionnaire about health habits and risks such as smoking, drinking, exercise, or diet?
	Yes	63 (44)	85 (62)	148 (53)
	No	77 (54)	48 (35)	125 (45)
	Other	3 (2)	4 (93)	7 (2)
	Total	105 (100)	165 (100)	280 (100)
2.	Which alcohol related questions, if any, are on your questionnaire?
	Quantity and/or Frequency questions	46 (73)	64 (75)	110 (74)
	CAGE + (Quantity and/or Frequency)	9 (14)	14 (16)	23 (16)
	CAGE questions only	5 (8)	6 (7)	11 (7)
	None or left blank	3 (5)	1 (1)	4 (3)
	Total	63 (100)	85 (99)	148 (100)
3.	When patients answer alcohol questions (either written or verbal) in a way that concerns you, how do you usually handle it?
	Note in chart (Discuss and/or Refer)	64 (45)	59 (44)	123 (44)
	Discuss only	56 (39)	57 (43)	113 (41)
	Discuss and Refer only	12 (8)	16 (12)	28 (10)
	No formal policy or Refer only	11 (8)	2 (1)	13 (4)
	Total	143 (100)	134 (100)	277 (99)
4.	If you are not routinely screening for heavy drinking and alcohol related problems, would you be open to adding a few standardized questions to your current screening practices?
	Yes, but would add verbally	34 (52)	24 (63)	58 (56)
	Yes	14 (21)	9 (24)	23 (22)
	Do not think is useful	6 (9)	1 (3)	7 (7)
	Other	12 (18)	4 (11)	16 (15)
	Total	66 (100)	38 (101)	104 (100)