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Illicit substance use is highly prevalent in US urban settings and impacts much of the patient population served by our faculty, residents and students. Our city has consistently ranked in the top 5 US metropolitan areas for emergency department drug episodes during the last decade. Drug overdose was the seventh leading cause of death for men in 2003–04.
There is an urgent practical need to have substance use issues taught to medical students. Patients who use illicit substances represent an especially vulnerable group and are over-represented as patients in teaching hospitals. Unfortunately, the so-called ‘hidden curriculum’ often introduces clinical and interpersonal biases that interfere with best clinical practice. In addition, exposure to substance-using individuals in clinical settings can be frustrating for inexperienced students and clinicians and may lead to burnout. Intermixing community-based experiences allows students to experience other philosophies and modalities in caring for urban poor populations and to develop an understanding of substance-using patients in their wider sociocultural contexts.
We designed a multi-disciplinary Year 4 elective to increase students’ understanding of the complexities of substance use in the social world outside clinical settings. This course was integrated with an elective on clinical care for urban poor populations. Both courses provide students with multiple community perspectives on providing care, including harm-reduction protocols, to marginalised populations. The 2-week substance use course is described below.
This course has been run twice in concurrent years and has been well received by students and the community. Overall students’ course ratings were 4.75/5.00 (n = 12). Specifically, students were very satisfied with writing and discussing their fieldnotes; they uniformly described that experience as helpful in enhancing communication and observational skills. One student felt ‘enlightened’ by writing fieldnotes and commented, ‘I found myself observing everything more keenly.’ All community-based programmes, sometimes reluctant to establish rapport with medical entities, agreed to work with us in the second year based on their positive experiences in the first.
The writing and sharing of ethnographic fieldnotes during clinical experience is, to the best of our knowledge, unique in medical education. The practice helps to achieve several of the objectives of this course: it enhances competency in working with substance-using individuals; it improves observational skills; it promotes critical self-reflection; it develops a practical awareness of the clinical utility of anthropological methods and philosophy, and it encourages reflection on the challenging experiences that are inherent in providing inner city care.