Chief residents from all over the country joined faculty, fellows and scholars at Endicott College for the 25^th annual Immersion Training in Addiction Medicine, May 5. Photo by Doug Fraser

Health & Medicine

Chobanian & Avedisian School of Medicine’s Chief Resident Immersion Training (CRIT) Marks 25th anniversary

Program helps new chief residents diagnose, treat, and teach about addiction

On a spring day this past May, Denny DesRosiers pulled up in front of the Wylie Inn and Conference Center at Endicott College in Beverly, Mass., and threw open the rear doors of his van, revealing what could easily be mistaken for a tradesman’s wall of shelves and bins. But these containers were not filled with pipe clamps or nuts and bolts.

Standing at the open doors, physician Kiara Taquechel took a heroin “cooker” from DesRosiers, a harm reduction specialist with Healthy Streets Outreach Program, which provides HIV/AIDS prevention and overdose prevention services to North Shore residents with active substance use, and their families. The cooker, used to dissolve powdered or solid drugs into an injectable solution, looked like a votive candle tin. Taquechel listened as Desrosiers explained that it wasn’t perfect—people could burn their fingers using it—but it was more sanitary than using bottlecaps or other things found on the street.

“We meet people where they’re at. We do everything from blood draws to wound care, out of the van. We give out supplies, anything from injection, smoke, to sniff supplies,” says DesRosiers. “We’re not doctors, but we try to take care of people the best we can.”

Of course, Taquechel is a doctor, a newly selected chief resident in internal medicine at Beth Israel Deaconess Hospital in Boston. Along with 23 other incoming chief residents and three faculty mentors from all over the United States, Taquechel was getting firsthand experience talking to those with substance use disorders and attending lectures, skills trainings, and mutual support meetings, like Alcoholics Anonymous, at the 25^th Annual Chief Resident Immersion Training (CRIT) in Addiction Medicine, held in early May on the campus of Endicott College. The Fellow Immersion Training program for clinical subspecialty fellows and the Boston University Chobanian & Avedisian School of Medicine’s Clinical Addiction Research and Education (CARE) Faculty Scholars program for residency program faculty also were held at the same time, with nine fellows and 12 faculty scholars participating.

CRIT began in 2002, led by Jeffrey Samet (SPH’92), professor of medicine at the School of Medicine and Daniel Alford (SPH’86, CAMED’92), professor of medicine and associate dean of the Center for Continuing Education at the School of Medicine. With faculty drawn mainly from Boston Medical Center (BMC) and BU’s medical school, the training is funded by the National Institutes of Health and the National Institute on Drug Abuse.

“I joined the faculty at BU in 1989, and I was interested in addiction and HIV, but there weren’t too many of my colleagues with those interests,” Samet says. “Our CRIT program has proven to be highly effective in teaching the teachers creative approaches for elevating physicians’ care of patients with alcohol and drug problems. The path is steep and long, but rewards are very satisfying—for patients, physicians, and faculty.”

Alford was a chief resident and new faculty member at BU in 1996 when Samet introduced him to the field of addiction medicine and the need for educating others about this important area of clinical care, he recalls. The two decided to focus on training incoming chief residents, who are selected as outstanding clinician educators by their residency program directors, to spend a year training residents and medical students.

Over the past 25 years, nearly 600 chief residents have participated in CRIT, as well as 165 of their faculty mentors, coming from more than 250 residency programs in nearly 40 states.

“We have physicians [attending the training] who are pretty well-versed in addiction medicine but want to learn more, and then we have folks who come from areas where there are very few addiction medicine champions and they’re here to try to be one of the emerging champions at their institution,” says CRIT faculty member Hallie Rozansky, assistant professor of medicine at the School of Medicine, associate director of the BMC Internal Medicine Residency Program, and a CRIT alumna from 2020.

“I’ve always had an interest in addiction medicine, but no formal training,” says Kellner Pruett, a physician who works at Cone Health Family Medicine in Greensboro, N.C., and was attending CRIT as a CARE Faculty Scholar.

The main deliverable coming out of the immersion training is a project proposed by each participant as a prerequisite for admission, and refined over the three-day program, that will enhance addiction training for their residents and medical students.

“One of [Cone Health’s] biggest needs was an addiction medicine curriculum,” says Pruett, whose project for the training program reflected that need.“We’re instituting a protocol for opioid use disorder (OUD) screenings so that when someone screens positive for OUD, we’ll have a plan in place for the residents to know the medicines to prescribe, where to send patients, and what community resources are available.”

“I think it’s important for us to show what we’re able to do in Boston and Massachusetts, but it’s equally as important for us to hear how people are doing what they can do where they live,” says Alexander Walley (SPH’07), professor of medicine and co-principal investigator with Samet of the CRIT addiction program. He was a CRIT participant as a chief resident in 2003.

“Some of the most innovative and creative things come out of the communities that face the most stigma and adversity. People find a way to do their best to meet the needs of the people they’re trying to take care of,” he says.

CRIT faculty member Jessica Calihanis a 2020 alumna of the program. She recalls working as a medicine-pediatrics resident at Johns Hopkins Hospital in Baltimore, Md., when her chief resident returned from CRIT with a project that changed how they treated patients with substance use disorders.

“It was really transformative,” says Calihan, now a pediatrician at Massachusetts General Hospital specializing in adolescent and addiction medicine and an instructor at Harvard Medical School. “I think it is so helpful for people to come and learn from experts, and then bring it home to their institution, where there may not be the expertise that exists in a place like Boston Medical Center.”

For her project, Taquechel focused on a curriculum for residents on how to manage opioid withdrawal in the hospital that included learning-based lectures and interactive case-based workshops with expert consultants. Reviews of her project by CRIT faculty prompted Taquechel to focus on how to ensure her program continued after her year as chief resident was completed. She decided to create a teaching guide, record the training process, and publish training materials online for future chief residents to use.

“I was struck by the generosity of the [CRIT] faculty,” says Taquechel. “They shared their materials with us; they shared their time. The goal is education without ego and I’m really grateful for that.”

Nicholas Imperato, the chief resident of emergency medicine at Rutgers’ University Hospital in Newark, N.J., says around one-quarter of patients have substance use issues. The CRIT training was an eye-opener, he adds.

“There were so many different topics, areas of research and treatments and resources,” Imperato says. “Even though we see a lot of patients with alcohol- and opioid-related complications, there’s so many other resources and treatments I wasn’t aware of that we can offer patients dealing with substance use.”

According to a recent Massachusetts General Hospital Research Recovery Institute study, one-in-five patients with substance use disorders discharged from emergency rooms returned within 30 days. Recidivism can be discouraging, even for a seasoned care provider, and CRIT exposes participants to new approaches and innovative programs.

“This is a very challenging patient population to work with, but it was very encouraging for me to see that the system can work, the medications can work, our training can work, even if it doesn’t always feel that way on a daily basis,” says Anita Mudan, a Rutgers University Hospital emergency medicine physician. She came to CRIT with Imperato as his faculty mentor working on their project to integrate more addiction medicine training into the first-year EM residents’ addiction medicine rotation through an online course on substance use disorders that residents can work on in their down time.

Lectures and skills practice are valuable, Taquechel says, but she was most enriched by the first-person interactions like the Healthy Streets van, the recovery support meetings, and other opportunities CRIT provides to engage directly with people with substance use problemsg. She also appreciated the knowledge and compassion CRIT faculty brought to their work.

“I left feeling invigorated as CRIT crystallized how education can be a powerful advocacy tool,” says Taquechel. “I’m returning home excited to strengthen our addiction curriculum with the goal that every patient, no matter where they are in their journey, is met with dignity, compassion, and thoughtful care.”