Session 123

Dr. Sheila Specker is an Addiction Medicine specialist and psychiatrist, and fellowship director at the University of Minnesota. Today, she walks us through her unique, long path going through Family Medicine and then into Addiction Medicine Fellowship, and then back to Psychiatry residency.

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[01:08] Interest in Addiction Medicine

Sheila got interested in Addiction Medicine and Psychiatry back when she was a medical student, specifically during her 3rd-4th clinical rotations. Her hospital had a very active susbtance-use treatment program. She noticed it was less pathology-oriented than being health-oriented so she decided to participate in the two-week experience.

She went into Family Medicine and what she particularly liked about it was the continuity and seeing families over time.

After residency in Family Medicine in Wisconsin, she went back to Minnesota to do an Addiction Medicine fellowship. At this point, she realized how many comorbidities it had with other mental health disorders. She then decided to do a psychiatry residency. After all this, she joined the faculty at the University of Minnesota.

[04:44] Traits that Lead to Being a Good Addiction Medicine Specialist

The ability to work with people where they’re at is important. You have to be able to look at the pros and cons and their level of motivation. How do you move it to a point where they’re willing to do something?

A motivation interview is a good approach for all illnesses. They teach students early on about motivational skills and how important it is. This gives patients the ability to make those decisions. 

[06:35] Types of Patients and Typical Week

They’re seeing patients of all types of substance abuse. Presently, they’re seeing a lot more opioid problems. She’s also the medical director of a residential treatment program and a lot of patients with opioid problems come into their program.

Her typical week would look like spending a day a week as a medical director and addiction psychiatrist at the residential treatment program. She supervises addiction medicine fellows. If they have residents interested in addiction, this would be another day in a week. 

She spends another day a week for clinic, which is a dual disorder clinic (substance + other mental health problems combined). She also does research where she spends a couple of half-days a week for it. 

Additionally, she does consulting work. She is a medical consultant for their health professional services program. It’s a monitoring program for licensed healthcare professionals with addiction and other mental health problems.

[09:10] Getting Help as Physicians

The health professional services program protects the license of licensed health professionals with addiction or other mental health problems. They do whatever they need to do and the licensing board does not find out about this. 

Moreover, there are many institutions that offer private, confidential services that do not get reported anywhere. It’s completely separate from even health insurers. 

Sheila wishes people to understand that addiction, depression, and anxiety are illnesses. Therefore, we need to get appropriate care for these illnesses. And like any other chronic illness, early intervention is critical.

[11:00] Taking Calls

Addiction Medicine specialists don’t generally take calls. They work during usual hours. All addiction medicine specialists in the private sector also don’t take calls.

In emergency room settings, they’re not generally equipped to manage mental health and substance use other than the acute manifestations. And Sheila admits this is a great problem nationwide. Partly, this is because of a lack of training.

Many emergency room doctors are not licensed to prescribe buprenorphine, which is one of the most important treatments for opioid use disorders. This impedes patients from getting the help they need.

Many systems are developing bridge clinics to address this problem but there’s still a demand for trained physicians in providing this.

[13:30] How to Stand Out for Fellowship

Medical students can do a specific rotation in addiction. Psychiatry and Family Medicine are the two most typical departments that would offer addiction medicine rotations.

[13:30] How to Stand Out for Fellowship Application

Medical students can do a specific rotation in addiction. Psychiatry and Family Medicine are the two most typical departments that would offer addiction medicine rotations.

Most of their residents graduate from Family Medicine or Internal Medicine programs. This is not required, however, as residents can come from other specialties like pediatrics, OB/GYN, etc. Psychiatrists often take the route of doing addiction psychiatry fellowships.

The reason for this has largely been accreditation. Addiction Psychiatry programs had accreditation back in the 90’s. And there wasn’t an official accreditation of addiction medicine until two years ago. 

Eventually, addiction medicine acquired subspecialty recognition. Interestingly, addiction medicine is under the board of Preventive Medicine as a subspecialty.

Their fellows are not necessarily those who have just graduated from residency. Some physicians have been out in practice for some years until they decided to make a switch into addiction medicine.

[17:10] What Fellowship Looks Like

You need to have some training in an inpatient setting. This typically might be at an inpatient detox unit, consult liaison service in the medical and surgical units, or a residential treatment program.

The bulk of most training now is in the outpatient sector because it’s where most physicians will be in practice unless you are a hospitalist. 

Other experiences would be in areas of adolescence, geriatrics, neonates, and neonatal abstinence syndrome. They all have a continuity clinic and their own patient panel that continues through the duration of their one-year fellowship. Some could be at an intensive outpatient program. 

The physician might be a lead but it’s a very interdisciplinary team. Other members of the team include psychologists, social workers, residents, substance use counselors, and case managers.

[19:40] Academic vs Community Setting

Sheila took the academic route over the community-based setting because she loves research. She also had wonderful mentors that were faculty. This basically drew her into academic medicine, having been able to partner with one of their faculty to come on board.

Moreover, there were not a lot of outpatient practice opportunities at the time of her residency. This has changed dramatically through the years though. But once she got into academic medicine, she found she enjoyed teaching. She also loves being a program director for which she has been serving such a role for 15 years now.

[21:39] Advice for Future Primary Care Physicians

Some schools would have only a few hours of direct exposure in the classroom. Nevertheless, what she wishes that primary care physicians would realize is that it’s very to see the end-stage results. 

It’s easy to see the end-stage results if you’re on an inpatient medicine service and you see cirrhosis, for instance, from alcohol. Then you can become jaded by that. 

Whereas seeing people recover in the outpatient setting through treatment. Having that continuity experience in the outpatient setting is really critical.

[23:00] Subspecialty Opportunities

There are some who become interested in academic medicine. Another common avenue is becoming assistant program directors for fellowships. Others go into direct addiction medicine practice itself.

Other graduates can also go back to a primary care setting to provide consultation and help with their colleagues in primary care. 

[24:15] What She Wished She Knew that She Knows Now

She wished she recognized more the stigma behind this along with the underpinnings of addiction being neurological. There is brain science behind addiction. 

A lot of that information wasn’t available until the recent 5-10 years that we’ve learned a bit about the brain and what happens with the use of substances. For example, changes in the brain with opioids probably don’t return back to normal which is why we use opioid-agonist therapy.

[25:25] The Most and Least Liked Things

What Sheils likes most about her practice is the diversity her specialty brings. She gets to learn about the patient and be with the patient through their struggles and to the other side.

On the flip side, what she likes the least is the insurance issue which is an ongoing struggle. Sheila is involved in their psychiatric society in the current administration. They do lobbying and they’re very involved in parity for both mental health and substance use. 

It may take legislative efforts to achieve that and Sheila believes they all need to be advocates for their patients to achieve this.

[28:13] Changes and Myths

In terms of the major changes in the field of addiction medicine in the future, neuromodulation is one of the areas that they’re involved with. TMS (transcranial magnetic stimulation) is one modality to look for as well. 

The biggest myth about their field is that it’s not treatable or that it’s not satisfying. This all boils down to education and medical schools should also focus on this. But if she had to do it all over again, Sheila would still have chosen the same. 

[31:05] Her Thoughts on Decriminalization of Illicit Drugs

Sheila is definitely in favor of decriminalization. The American Society of Addiction Medicine has come up with a very strong statement to this effect.

Around 70% of people in jail will have a substance problem and it might be for something minor. 

Some systems are looking at getting incarcerated people getting adequate treatment as they leave the prison. Most societies, in fact, are in favor of decriminalizing. It’s not the same as legalizing certain substances.

[32:40] Final Words of Wisdom

If this is something you’re interested in, contact an addiction medicine specialist and spend time with that person to give you a good perspective of what the field is like.

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