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What is Recovery?

An essay on the subject of “What is Recovery” raises, for me, the question of what is Addiction. Since everyone of us has an idea, our own idea, of what Addiction is, we'll also have our own answer to “What is Recovery?”

Since we don’t have agreement in our field on what Addiction is, I doubt that we can come up with an easy agreement on what recovery is. I could just tell you my definition of both but my goal is not for us to have a debate over which we can come to a resolution. My goal is that we all look at ourselves and how we got to this question. It may be, that after examining ourselves, we may choose to change the question we ask.

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Its How Weve Always Done It

Written by Stuart Gitlow MD, MPH, MBA

Tuesday, 22 July 2008 08:24

The process of becoming an addiction-certified physician is laborious.

There are two current routes. The one that has been available the longest is through the American Society of Addiction Medicine (ASAM). Within this process, one must first complete a medical residency in any specialty, and then spend a year working in the field of addiction, at least half of which must involve direct patient care. Further, 50 hours of addiction-specific training must be received. The ASAM certificate is not a certificate of the American Board of Medical Specialties, though it is generally recognized as being an equivalent. Maintenance of the ASAM certificate requires that the holder go through recertification (and re-examination) every decade. The second route is available through the American Board of Psychiatry and Neurology (ABPN), and is open only to ABPN-certified psychiatrists who have taken a one year fellowship in addiction psychiatry. Roughly 1,000 medical students each year enter the field of psychiatry; and fewer than 5 percent continue beyond the end of their psychiatric training to take the one-year fellowship. This certification also requires an ongoing maintenance program and reexamination over a 10-year period. Psychiatrists can choose either the ASAM certificate or the ABPN Board certificate, or even take both. Non-psychiatric physicians can take only the ASAM examination.

So, why are there so few?

At the very end of psychiatric residency, the physician is at least 29-years-old, but is likely closer to age 30 or 31. He or she will typically have never held a full-time job and will have a debt of roughly $200,000. That person can make a choice: 1) start practicing as a psychiatrist with an income of $150,000/year and have a chance of paying off their debt by the time they are 40; or 2) take another year of training with an income of $50,000/year, delay the debt payback, and move once — probably twice — in the next two years. You can understand why so few pick the latter route, particularly since the extra year of training does not result in any increase in eventual income.

Once a physician is in practice, it is rare that they say, “I think I’ll shut down my practice, tell all my patients to go somewhere else, and take another year of training.” So, if a physician leaves residency and goes directly into practice without pursuing one of the two routes to being addiction-certified, we aren’t likely to see them in the future — unless something goes wrong in their lives. That third route, if you will, isn’t particularly unusual, but it represents a special case. We are not likely to either increase or decrease those numbers (at least not in this column), so instead we must focus on increasing the number of docs entering the field immediately after residency. Why? Because we have an insufficient number of physicians with knowledge and interest in this field.

Psychiatry residency is a four-year process. Child psychiatry is a two-year fellowship. The first year of child psychiatry overlaps the fourth year of general psychiatry residency. One can, therefore, finish a combined program in five years. Why then cannot the addiction psychiatry fellowship also overlap the fourth year of psychiatry residency, such that the physician is finished with the combined program in four years (or four years plus a few months, perhaps). No one really cares if they finish their residency precisely at the end of June. After 25 years of school, the precise month of completion isn’t critical. But that extra year seems to put things a long way off. Can we not adjust that simply because it has never been done?

Why must the fellowship be the formal process that it is through ABPN? Perhaps the ASAM approach is better in allowing physicians to “count” a year of work in the field, at a normal income level, as being the critical element. As we move with the new American Board of Addiction Medicine (ABAM) into the future, one might be concerned that only formal fellowship pathways would be available to physicians, making it perhaps even less likely that physicians will enter the field than they do now. ABAM will need to closely study the patterns of entry into the field over the past years in order not to cut off those likely to enter the field in the future.

Addiction — stepchild of diseases

It is certainly interesting that addictive disease has the same stepchild image within the field of medicine that it does among the lay public. Even in Washington, there are real diseases; then there are mental health conditions; and, oh yes, then there’s that addiction problem. For many years no one in medicine took ownership of addiction, though those practicing in the field were predominantly internists. Then psychiatry picked up the field, but only to the extent that five percent or so of graduating residents enter the fellowships.

I’d like to think that any disease that impacts 10 percent of the public would garner extensive interest by health professionals, but interest can be trumped by economic and chronologic realities. If we’re going to make it so that more physicians enter the field and practice addiction medicine, we have to make broad and sweeping changes to the system as currently designed. Outcomes of these changes need to be closely followed to ensure that we are addressing the needs of the 30-year-olds as they make their choice regarding whether to enter the field. We want them here. They, I hope, want to be here (and more on that next time). So let’s not put up so many roadblocks that they throw up their hands in dismay.

This column represents Dr. Gitlow’s personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

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