As a medical student, do you ever wonder what it’s like to specialize in addiction medicine? Meet Louis E. Baxter, MD, an addiction-medicine specialist and a featured physician in the AMA Wire® “Shadow Me” Specialty Series, which offers advice directly from physicians about life in their specialties. Check out his insights to help determine whether a career in addiction medicine might be a good fit for you.
“Shadowing” Dr. Baxter
Specialty: Addiction medicine.
Practice setting: Group.
Employment type: 501(c)(3), president and CEO.
Years in practice: 39.
A typical day and week in my practice: In a typical day, I may see between 12 and 15 patients. Some of those patients are for follow-ups, others are initial evaluations for the presence of substance-use disorders or psychiatric conditions. Our clients are self-referred in that they determine that they may have a problem. Most of them are referred by colleagues in their practice, colleagues at the hospital and, in many instances, from the state licensing boards.
When we see brand-new patients, we do a comprehensive evaluation to determine if they met any of the diagnostic criteria for substance use disorder, psychiatric illness or any behavior abnormalities. Once that is determined, we will construct a treatment or monitoring plan for each individual. In cases that involve substance-use disorder, we use the American Society of Addiction Medicine criteria to determine what level of care a person requires in terms of substance-use disorder treatment. In those particular cases where substance use is involved, we will schedule random urine drug testing to verify that they are free of drug and alcohol use, but also to see how well the treatment plan we have developed is working.
For those individuals who have a psychiatric illness we will need to determine what the DSM-5 diagnosis is, then refer them for their appropriate follow-up, whether that is psychiatric care, counseling or, in some instances, both. Very rarely, we need to refer people for partial hospitalization programs and, in some instances, hospitalization. Likewise, we develop a treatment plan for them.
In a typical week, our office is open from Monday–Thursday from 8:30 a.m. to 4 p.m. We are open a half day on Fridays. Mainly, that is for administrative catch-up.
The most challenging and rewarding aspects of addiction medicine: The most challenging aspect of caring for patients in my specialty is not so much making the diagnosis. We have the tools, such as the DSM-5, to help make the diagnosis of substance-use disorder or psychiatric illness. We also have the American Society of Addiction Medicine criteria to determine what level of care a person needs.
The most challenging aspect, however, is getting patients the level of care they need and the coverage for the level of care that is required. Many insurers have roadblocks that have to be cleared in order for some of our people the get the treatment that they need. There’s a medical necessity requirement imposed by some insurers, which is perplexing because, after all, we are the physicians making the diagnosis and developing the treatment plan, so it should be apparent that there is a medical necessity for the request of services.
Another challenging aspect, which is more germane to the patient, is patient acceptance. Some patients do not wish to accept their diagnosis. We find that with substance-use disorders when patients are in the early stages of their diseases. I believe that is because they haven’t had enough consequences to occur to help dampen that denial. On the psychiatric side, a lot of clients who suffer from bipolar disorder enjoy the manic phase, and they don’t think there is anything wrong with having extra energy or being able to stay up late at night working on perceived important projects.
The most rewarding aspect of addiction medicine is that you can see patients progress from sickness to wellness in a relatively short period of time. I’m primarily trained as an internist, so I am familiar with working with chronic medical illness. In internal medicine, sometimes people do not get well for years, and in some instances, they never do. However, in addiction medicine, when we are able to make an accurate diagnosis of all the factors involved—in terms of an actual substance-use disorder, if there is a presence of any psychiatric condition, if there are any physical or pain conditions—and we develop a treatment plan, we can see results usually within a very short period of time. It’s rewarding to see folks that were down and out—in terms of their health and their life, their ability to earn and care for their family—return to become healthy and contributing members of society.
My subspecialty in addition medicine is health care professional impairment. It’s is a great pleasure for me to be able to help these individuals treat their addictions and mental health issues and continue them on their path toward practicing medicine.
Three adjectives to describe the typical physician working in addiction medicine: Most physicians who are in addiction medicine are caring, effective in understanding and promoting the concepts of addiction medicine and addiction treatment. And, lastly, I would like to say that they are eligible, meaning they are board certified.
How my lifestyle matches, or differs from, what I had envisioned: I never envisioned practicing addiction medicine in medical school. I went through medical school in the 1970s. My vision was being an internist. I was thinking that if I worked hard and did a good job, I’d make about $50,000 a year and I’d be in a very good position. I obviously didn’t know how much it took to practice internal medicine at an effective level. When I graduated, I found that you need to spend at least 60 hours a week in the office, if you are a solo practitioner, and you needed to spend 24 hours and seven days a week available for call.
For the 11 years that I practiced general internal medicine, I did not have a good quality of life. Addiction medicine, however, has given me an opportunity to have a much better practice lifestyle. Having primarily been trained as an internist, I have an ability to evaluate my patients very well in terms of their medical needs. The way that addiction practice has developed over the years, there is no need in most cases to be available 24 hours a day, seven days a week. We have various levels of care in which to refer our patients in to, and we have the ability to practice in groups. So I have more time available for family and I can pursue more work-life balance.
Skills every physician in training should have for addiction medicine but won’t be tested for on the board exam: Physicians need to have a broad sense of general medicine because substance-use disorder affects all organ systems. Many times, patients will present with complaints that seem distant in terms of their relation to substance-use disorders, and if you are unaware you may miss that diagnosis.
It’s also important that physicians have empathy for patients who have substance-use disorder because some of the behaviors that are a part of the disorder are despicable—lying, thieving, being less than accurate with responses are all part of the disease. When physicians who are going to be in this specialty find themselves turned off by some of these behaviors, it may make it difficult for them to practice.
These qualities or attributes are not easily tested for on certification examinations, but rather these are characteristics that can be observed and developed when physicians are in addiction-medicine training programs.
One question physicians in training should ask themselves before pursuing addiction medicine: The one question that physicians should ask themselves is very basic: Do they believe that substance-use disorder is a chronic medical illness. If the answer is yes, they should proceed. If the answer is no—that they think it’s bad behavior or a lack of willpower—they should pursue something else.
Books every medical student interested in addiction medicine should be reading:
- The ASAM Essentials of Addiction Medicine, edited by Abigail J. Herron, DO, and Timothy Koehler Brennan, MD, MPH.
- It Happens to Doctors, Too, by Abraham J. Twerski, MD.
- The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions, edited by David Mee-Lee, MD.
The online resource students interested in addiction medicine should follow: ASAM.org, the website of the American Society of Addiction Medicine.
Quick insights I would give students who are considering addiction medicine: Addiction medicine is a comprehensive medical specialty that involves general medicine, psychiatry and pharmacology. There is opportunity for preventative measures as well as treatment.