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Keywords:

  • Addiction medicine;
  • alcohol and drugs;
  • income;
  • recruitment;
  • status;
  • subspeciality

Soyka & Gorelick [1] deserve strong praise for raising a critical and unjustly neglected concern. Substantial advances in alcohol and drug research, policy and practice will have minimal population impact unless there is a significant expansion of the committed health care work-force, especially doctors. These authors assume that shortages of doctors entering the alcohol and drug field are virtually universal. Although they provide minimal supporting data, their assumption is probably correct. But is it really a shortage of young medical recruits or a lack of suitable positions? Of course, we should always be wary about conclusions drawn from so little evidence. Accordingly, the questions raised by Soyka & Gorelick deserve systematic research. In the absence of available data we can only speculate about the relative importance of factors that attract or deter young doctors considering entering the alcohol and drug field.

Soyka & Gorelick argue that this field should be an attractive discipline for doctors: not only do alcohol and drug problems impose substantial burdens on communities, but also far more effective treatments are rapidly becoming available. Their main recommendations to increase recruitment include recognition of addiction medicine or psychiatry as a subspeciality, reducing discrimination against alcohol- and drug-dependent people and increasing incomes for subspecialist doctors. These recommendations are largely interlinked. Recognition of the field as a subspeciality is likely to increase incomes for addiction subspecialists in many countries, while recognition of this discipline and increased medical incomes will inevitably raise the status of the field.

How much of the low status of this discipline derives from the low status of their patients? For most members of the medical professions, the alcohol and drug field is perceived as reserved for those incapable of obtaining entry to a higher status speciality or others previously incapacitated by severe alcohol and drug dependence. As long as community responses to drugs such as heroin, cocaine, amphetamine and cannabis are defined as essentially matters for drug law enforcement, people who use these drugs and their clinicians will inevitably be severely marginalized. Yet despite the entirely legal nature of alcohol dependence, patients and clinicians alike have long been and still are relegated to low status. A more health-orientated approach to illicit drugs might make the status of illicit drug users and their clinicians less marginalized, but it is hard to think of any way of improving the low status of alcohol-dependent patients and their clinicians.

The alcohol and drug field is also a relatively poorly paid speciality for doctors. In many countries, young doctors who choose this speciality either have a precarious and modestly remunerated future in the public sector or an even more precarious and even more modestly remunerated future in the private sector. While some doctors are motivated almost entirely by financial considerations, many aspire only to reasonable comfort and family security. Sixty years ago Nye Bevan famously argued when establishing the National Health Service in the United Kingdom that doctors change their behaviour when ‘their mouths are stuffed with gold’. Ensuring attractive remuneration to a speciality is impossible while it occupies such a lowly position in the medical speciality hierarchy.

The alcohol and drug field continues to be dominated by psychiatry in most countries [2]. While mental health is and should always remain an important part of the alcohol and drug field and notwithstanding the many illustrious contributions made to this field by many psychiatrists, psychiatric domination of alcohol and drugs probably deters many more young doctors from considering this field than it attracts. Many young doctors who, quite properly, regard this field as a quintessential bio-psychosocial discipline will be deterred by the absurdly simplistic notion that ‘addiction is a brain disease’[3]. In Australia, young doctors are being recruited to the Chapter of Addiction Medicine in the Royal Australasian College of Physicians from the ranks of physicians, psychiatrists and general practitioners. This Chapter has a strong commitment to training, public health, alcohol and drug policy development and advocacy. The vision of alcohol and drugs as a mere subset of psychiatry is ridiculously narrow. If the alcohol and drugs subspeciality is to ever achieve benefits at the population level serious attention has to be directed at the sizeable non-clinical populations, which can only be achieved by working for system changes and developing much closer partnerships with general practitioners [4].

As Soyka & Gorelick rightly point out, the alcohol and drug field has a reputation for clinical ineffectiveness and irrelevance. This is increasingly underserved. The exaggerated emphasis in global drug policy on the mood-altering drugs included in the three major international drug treaties (1961, 1971 and 1988) and the neglect of the far more important legal drugs, alcohol and tobacco, is ludicrous. Until there is widespread recognition that the substantial commonalities far outweigh the difference between alcohol, tobacco, prescription and illicit drugs, the alcohol and drug field will remain marginalized.

References

  1. Top of page
  2. References
  • 1
    Soyka M., Gorelick D. A. Why should addiction medicine be an attractive field for young physicians? Addiction 2009; 104: 16972.
  • 2
    Wodak A. Whose territory is it anyway? Should psychiatry own alcohol and drug in Australia? Aust NZ J Psychiatry (Editorial) 1994; 28: 3757.
  • 3
    Leshner A. I. Addiction is a brain disease. Issues on Line in Science and Technology. Natl Acad Sci 2001. Available at: http://www.issues.org/17.3/index.html (accessed 11 August 2008).
  • 4
    McAvoy B. R. Addiction and addiction medicine: exploring opportunities for the general practitioner. Med J Aust 2008; 189: 1157.