Country Profile - Scandinavia

There is a long history of discussing alcohol problems in medical training, though the number of hours and the formal structure has varied over time and between countries. The WHO, the European Monitoring Centre for Drugs and Drug Abuse (EMCDDA), as well as the American Association for Medical Education on Alcohol and Drug (AMERSA) have been active in giving support to programmes, teachers, and research.

In some Scandinavian countries, medical teachers with a personal interest gave lectures and distributed material. In Sweden as early as the 18th century Carl von Linné warned against alcohol, and Magnus Huss published an excellent monograph "Alcoholismus chronicus" in 1849 and 1851 which was translated into German and for which he received a French reward. During both clinical and pre-clinical courses, alcohol and other dependence-producing drugs have been mentioned to a varying degree. It was usual for only the later stages of dependence to be mentioned, but very little about early diagnosis, alcohol and drug policy, and prevention.

When the Karolinska Institute produced a new curriculum for medical students in 1983, "beroendelära" or "addiction medicine" was introduced as a mandatory course with 40 hours of of lectures and seminars, 40 hours of clinical training, and a final written examination. Problem Based Learning has later been introduced. Not only is knowledge important, but also the attitudes of students and doctors to alcohol and drug patients and to research.

In Sweden, continuing education was usually not given at universities but was to a large extent organised by the Swedish Society of Medical Sciences and its various Sections. The Section on Addiction Medicine was founded in 1956 and has about 300 members, with representation at the Annual convention of the Society, with workshops and study tours, the latest one during the spring of 1998 to Hungary. The Sections on primary care, general medicine, social medicine, paediatrics etc cover alcohol problems from time to time.

Research training is also important. In Sweden there are 7 professorships in alcohol and drug addiction research, and perhaps 50 theses have been presented. Lectures and seminars regularly occur in the various research departments. Research libraries are available.

Though much that is positive has happened, the situation is never stable. Organisation is fragile and often dependent on particular persons and devoted teachers. Some minimum standard should be guaranteed to ensure both progress and stability over the years.

Swedish education on alcohol and drug problems for medical students - a long term follow up

It has been asserted that doctors may have a negative attitude towards patients with substance abuse problems. A special two-week course in substance dependency was started in the basic training of doctors at the Karolinska Institute (KI) and was greatly appreciated. Five years later it was decided to poll the doctors concerning the basic training and dependency problems.

Method: The medical students who had studied substance dependency at KI in l984-85 and equivalent groups studying medicine at another University in Sweden, where there was a more limited form of instruction in substance abuse issues, answered a questionnaire concerning clinical experience of addicted patients, substance abuse problems, and the basic training.

Results: Responses were obtained from 112 of the 176 individuals. About 40 per cent had worked in a special unit for substance abuse patients, and 90 per cent had had patients with dependency problems and just as many had talked to the patients about their substance abuse. There was a general optimism concerning the possibility of treating substance abusers. However, the respondents were very pessimistic about their own ability to persuade patients to seek treatment and about half of them referred virtually none of their patients with drinking problems to a specialist treatment programme. The KI group was considerably more positive about its basic training in substance abuse matters than the corresponding group; otherwise, there were few significant differences. Almost all respondents stressed the importance of including substance abuse issues in the curriculum.

A Helsinki perspective on medical training about alcohol and drug dependence

The course on alcohol and drugs at the Faculty of Medicine of the University of Helsinki lasts for 1.2 study weeks. It includes two theme days and 32 hours of self-directed learning. The course is held during the last study year of the medical students. The main learning objectives are to give to every student basic abilities in the detection, diagnostics, and treatment of alcohol and drug related problems and diseases including substance dependency. The attitudes and communication skills are particularly emphasised. The course includes the use of a booklet entitled the ABC of Alcohol and Drugs. From the autumn of 1998 this booklet will be supplemented by a new Finnish textbook on addiction medicine. During the course an interactive large group problem-based leaning technique is applied. Furthermore the course includes a two hour visit of an AA-group. Videotapes aimed to improve attitudes towards alcoholics and drug abusers as well as those focusing on communication skills may also be used. An examination based on problem cases is mandatory for every student. During the past two to three years the course has been graded as one of the top three courses of our faculty.

The education unit of Alcohol and drugs of the county of Stockholm

The unit started 1990 and is financed mainly by the special clinics in Stockholm. The aims are to educate doctors, nurses, and paramedical staff in different aspects of the evaluation and treatment of alcohol and drug problems. Current courses are case management for patients with dual diagnoses, relapse prevention, and psychotherapeutic treatment for alcohol and drug patients. In addition there are plans for a new course in cognitive behavioural treatment of dependence disorders.

A two weeks full-time mandatory course in addiction medicine integrated in the internal medicine-surgery curriculum. Experiences from the Malmoe Model

Since 1992 a new clinical curriculum in the medical school at Malmoe General Hospital, University of Lund has been introduced. A two week problem-based course in addiction medicine has been integrated in the teaching of internal medicine-surgery including:

Theoretical learning: A textbook has been written defining the learning goals for medical schools.
Attitudes: the students' own attitudes towards alcohol drinking are discussed in small groups.
Practical skills:

A: The addiction interview.
B: Identification of heavy drinking and subsequent intervention.
C: Assessment of withdrawal symptoms.
D: Ethic analysis.
E: Developing an alcohol-prevention plan on the general practitioner level.
F: Regulations and laws. Case stories on children and spouses of alcoholics are analysed. Children or spouses of alcoholics attend the discussion.
G: Narcotic addiction. Identification of symptomatology indicating heroine, amphetamine and cannabis use.

Examination:
Practical and oral interviews as a part of the total examination of internal medicine and surgery.

Dr S. Larsson