As they were preparing for Step 1 of the United States Medical Licensing Exam (USMLE) in 2020, Yale School of Medicine (YSM) MD students Zoe Adams ’22, Elizabeth Fitzsousa ’21, and Marina Gaeta ’22 frequently saw terms such as “abuser,” “addict,” and “alcoholic” within popular practice exam materials, including question banks—materials students spend hundreds, if not thousands, of hours using. They worried these outdated, stigmatizing terms for individuals with substance use disorders (SUD), and the frequent characterizations of people with SUDs as having negative behaviors such as being irresponsible and negligent parents, would perpetuate provider bias. Such bias can discourage people with SUDs from seeking or continuing care and negatively influence patient care and outcomes.
Adams, Fitzsousa, and Gaeta say this concern led them to write, “Abusers" and "Addicts": Towards Abolishing Language of Criminality in United States Medical Licensing Exam Step 1 Preparation Materials, to advocate for change. Their article was published this past week online ahead of print in the Journal of General Internal Medicine. The authors thank Professor Anna Reisman, MD, director, Program for Humanities in Medicine and Associate Professor of Psychiatry Declan Barry, PhD, for their helpful input and guidance in writing the article.
Because of the structure of the YSM curriculum, Adams, Fitzsousa, and Gaeta all had the opportunity to take care of patients with SUDs and work with addiction treatment providers prior to studying for Step 1. “It was jarring to go from those environments where we saw models of what compassionate and de-stigmatizing care looked like, to transition to reading so many vignettes that mischaracterized and stigmatized people like our patients,” the authors said. They continue, “Yale's preclinical curriculum gave us fantastic faculty role models and a strong background to substance use disorder education and care.”
Most medical students in the U.S., in contrast, study for and take Step 1 before clinical rotations, and therefore the first exposure many have to patients with SUDs are through the exam preparation materials, with their harmful stereotypes and stigmatizing language. The authors explain that Step 1 integrates basic science into clinical scenarios, and students succeed by recognizing patterns and forming associations to identify medical conditions. The authors believe it is almost inevitable that students will internalize this derogatory terminology, since Step 1, by design, rewards pattern recognition that reinforces clinical and diagnostic stereotypes.
As they explain in their article, “most importantly, we wondered how our patients might feel knowing that future physicians were purposefully taught to associate their brain disease with a moral failing – and then rewarded for perpetuating this harmful misconception.”
The authors question why the study materials use terms such as “abuser” and “addict” that derive from the systematic criminalization of people who use drugs– and use them even when a patient’s substance use is not relevant to the clinical scenario—even though the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) introduced contemporary diagnostic categories for SUDs in 2013. They also criticize the study materials for not using person-first terminology, which DSM-5 also introduced. Person-first terminology aims to humanize patients and not have their medical conditions define them. For example, referring to someone as a person with an opioid use disorder rather than a “heroin user.”
They argue that inaccurate terminology cannot be explained by outdated materials, because question banks are continuously updated, and review books release new editions annually, noting that other important language updates are adopted.
They surmise the improper language and negative associations may reflect priorities, noting addiction medicine topics require a deeper understanding of the social dimensions of illness and are historically undervalued in medical education. SUDs are rarely integrated into the four-year curriculum structure and few schools require a course in addiction medicine. YSM, in contrast, in 2016 began reviewing the entire four-year curriculum to map out existing addiction medicine content, to see where core content needed to be added, and to look for opportunities for including aspirational content. This effort also involved revising existing content as necessary, such as to ensure proper language was used in discussing SUDs. Today, addiction medicine issues thoughtfully are woven throughout the four-year YSM curriculum, starting with Introduction to the Profession, which is medical students’ first course.
The authors end their article with specific calls to action. They call on the test preparation companies to rewrite Step 1 practice materials to remove stigmatizing language, urging them to consider the field of addiction medicine and its patients as seriously as other disease processes. They also encourage medical students, educators, and administrators to demand that test preparation companies make such changes, specifically asking medical students to provide the companies with feedback about questions using stigmatizing language or negative stereotypes to describe patients with SUDs. More broadly, they call on clinicians and medical educators “to confront their biases and recognize the power their language has on the next generation of physicians.”
Adams, Fitzsousa, and Gaeta know change will not be easy. There are dozens of different third-party prep materials for the USMLE, and many are large companies. For USMLE Step 1, most students use a combination of review books, question banks, and review videos. “Using at least some of these resources is essentially required to succeed on the exams, so boycotting or only selecting the ones that don’t use the terminology isn’t an option,” they explain.
The authors hope their article will help launch conversations about licensing exam preparation materials and the language used to describe patients with SUDs throughout all stages of medical education.