Impact of a Preclinical Elective on Medical Student Attitudes Toward People With Substance Use Disorders

Neonatal opioid withdrawal syndrome (NOWS) has become more common as the rate of opioid use in pregnant people more than doubled from 2010 to 2017. ^1,2  Stigma from medical providers toward patients who use substances negatively impacts health care outcomes, particularly in pregnant people with limited prenatal care.^3,4 Previous studies have shown that few trainees felt their training on substance use disorders (SUD) and trauma-informed care is adequate to deliver high-quality care to dyads affected by SUD.⁵ Barriers include the lack of physician role models and limited educational time, ^6,7 but even brief curricular interventions have improved student attitudes. ^8-11

One NOWS protocol with nonpharmacologic therapies and a simplified approach to assessing infants, called “Eat, Sleep, Console” (ESC), can positively affect outcomes. Compared to Finnegan scoring, ESC dramatically reduces both the proportion of infants treated with morphine and the average length of stay, without increasing readmission rates or adverse events. ^12-15 The shift from older protocols created an opportunity to educate medical students to provide better patient-centered care.

This pass-fail, preclinical elective combines five 1-hour didactics with case-based teaching, an interdisciplinary panel, and volunteer clinical experiences. The elective was started in January 2019. Students complete this optional course alongside the required preclinical 18-month curriculum. The course was created by resident and attending physicians in pediatrics, family medicine (FM), and addiction medicine, as well as maternity care nurses and medical students. Didactics, delivered across 3 months, covered NOWS physiology and treatment, standard newborn soothing techniques, trauma-informed care, and medication treatment for opioid use disorder in pregnancy. The panel, comprised of inpatient social workers, a certified drug and alcohol counselor (CADC), and a doula, discussed relevant social services. Students were required to serve at least two 2-hour volunteer shifts per month for 6 months, to assist nurses and parents with soothing techniques and ESC care for NOWS in the Neonatal Intensive Care Unit (NICU), mother-baby unit, and inpatient pediatric units. Finally, students wrote a 400-600 word reflective essay at the completion of the course on anything they learned that surprised them or changed their perspectives, meaningful interactions during volunteer shifts, and what (if any) experiences with SUD or maternal infant care they would like to pursue in their future.

We hypothesized that education and interprofessional exposure to NOWS would positively impact the perceived knowledge, attitudes, and beliefs of students toward people with SUD. This would augment earlier evidence by adding a multimodal analysis and interdisciplinary focus. ¹⁶

After obtaining institutional review board exemption, we conducted a mixed methods analysis for the first two cohorts (n=20). At their first and last course sessions, students filled out a survey (Table 1), adapted from the validated Drug and Drug Problems Perceptions Questionnaire (DDPPQ). The 20-item Likert scale questionnaire was designed to measure attitudes of professionals who work with people who use substances.¹⁷ Three questions were removed and five were added on student career goal intent to fit the scope of the elective (see Appendix 1). We analyzed responses through a Wilcoxon signed rank test using a Holm-Bonferroni correction for multiple comparisons.

A team of seven reviewers involved in the course conducted an inductive qualitative analysis on the 10 essays from the first term to identify recurring themes, which were then organized into a code set applied to the second term’s 10 essays and to survey items, to analyze response trends.

Of the 20 participants, there was a 95% paired survey completion rate. The qualitative analysis identified several major themes: perspective, professional identity formation, knowledge, confidence, empathy, gratitude, and interprofessionalism (Table 2).

The quantitative analysis revealed a statistically significant difference in seven survey items, shifting toward more positive perceptions and attitudes (Table 1). These included improved self-perceived knowledge and ability to find help for patient care, and increased respect for patients.

Finally, the combined analysis showed a subset of students who indicated lower confidence after the course in their ability to work with this population. Compared with students who had neutral or positive changes in their confidence, this group wrote more in their essays about implicit bias, and none discussed prior experience caring for people with SUD in their reflection essay.

Overall, this course improved many facets of medical students’ perspectives toward people with SUDs, showing that a course incorporating pregnancy and neonatal care can be effective, supporting findings from previously published data on SUD curricula. Quantitative improvement in attitudes correlated with qualitative themes of empathy, bias recognition, desire for further training in addiction medicine, and intent to include SUD treatment in their career path.

Many students described the interdisciplinary panel as a meaningful experience that yielded greater understanding of the social context of families with NOWS infants. Insight into interdisciplinary work is especially important in addiction medicine to combat pre-existing feelings of hopelessness or futility of treatment. ¹⁸ Acknowledgement of trauma-informed care and students’ own implicit biases may have built empathy for patients’ experiences to improve care.

The students who enrolled in the EMBRACE elective were self-selected, often with pre-existing interest in newborn care and/or SUD. This limitation was accounted for by measuring the change in the pre- and postsurveys instead of the raw numbers. The DDPPQ was adapted and lost validity from prior use but was more applicable to students. While the course was pass/no-pass, the reflective essays were a required component of the course which may have influenced responses. The small class size limited the power of our research, but should serve as early data for future, larger studies. Given the limitations of self-assessment of knowledge and communication, future research should include objective evaluation such as observed clinical encounters.

Family physicians are uniquely positioned to expertly care for patients with SUDs and NOWS given their broad training that encompasses the complex dynamics, integrating knowledge on trauma, mental health and SUDs with training in prenatal, obstetric, and newborn care. The creation of this course modeled collaboration between disciplines to educate learners to provide evidence-based, compassionate care. Additional research is needed to understand the generalizability and long-term impact of these efforts.