More Than Meets the Eye: Insights on Provider Stigma

An interview with Elisabeth Fowlie Mock, MD, MPH from the Maine Independent Clinical Information Service (MICIS).
​by Winnie Ho, Program Coordinator

​Tags: Detailing Visits, Opioid Safety, Stigma, Substance Use

Winnie: We appreciate you taking the time to speak with us today about the work that MICIS (Maine Independent Clinical Information Service) has done supporting evidence-based prescribing since 2008, and safer opioid prescribing since 2016. Can you tell us a little bit more about MICIS?
 
Elisabeth: We’re a small program created by legislation in the state of Maine, housed within the Maine Medical Association. We serve over 8600 prescribers including physicians, pharmacists, nurse practitioners, and physician assistants across the entire state. Our two detailers are contracted to work about 5 hours a week each, which includes all of our administrative and detailing time.

​​​Winnie: That’s an amazing feat to be serving such a large population with a small team. How have you built and maintained all of those relationships?

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Elisabeth: We have always used more of a general educational outreach approach than the traditional one-on-one academic detailing model. We have limited resources with our contract, and the only way to reach that number of prescribers is to do small groups or lectures.
 
Winnie: We understand that there are many programs who adapt the original model of detailing to allow for more than one provider at a time to participate. While it’s a common workaround solution to having limited resources and a long list of providers to detail, it can be more difficult to discuss challenging topics, especially something like opioids and related stigma. How have you been able to navigate those challenges?

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Elisabeth: When we detail in our groups, we focus on small group discussions. One method I use involves flashcards with myths or biases about Opioid Use Disorder (OUD) and Medication-Assisted Treatment (MAT), and asking two or three of the attendees to discuss that amongst themselves. We have also used a language sheet that guides providers in what to say.
 
We have people talk about the language commonly used in practice, and how that can affect the care that’s provided. I think just like any other place, we encounter people who have all of the biases that you’ve heard of when it comes to opioid use disorder – that it’s not a disease, that buprenorphine and methadone are just trading one drug for another.
 
Winnie: There must be a lot to unpack when discussing the root of where these beliefs come from. It’s a core component of what we hope to achieve through academic detailing – an honest dialogue that leads to positive clinical practice outcomes.

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Elisabeth: Exactly. I think it’s important to understand that, for example, with chronic pain prescribing, there are a lot of people who are reluctant to embrace evidence from the past five years that shows no benefit from opioids, and more significant evidence of harm. It’s been interesting to see how people have been stuck on what they learned twenty years ago, and to see them reject the newer information.
 
Winnie: It’s incredibly important that detailers remember in navigating tough conversations about stigma that there is a shared goal of promoting patient health. No provider undergoes training and hard work with the intention of harming patients.

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Elisabeth: I think these tough conversations can produce some cognitive dissonance in people. Basically, if I, as a physician myself, agree with the premise that what I did fifteen years ago actually contributed to OUD in my patients, and if I admit that, then I also have to carry a burden that it was my fault. It’s a hard jump for people who made it their life’s work to care for people.
 
Winnie: It’s absolutely a human response. What have you found to be an effective way of addressing the problems caused by stigma, while also addressing the fact that providers are human?
 
Elisabeth: People don’t want to be overwhelmed by data, but repeated snippets of data over time can help you reinforce the message, which is what we do with academic detailing. I think of myself in my work as a physician – I started on opioid education projects more than half a decade ago. It wasn’t my top choice, but I became more and more educated about the crisis and heard the information in multiple ways. It really changed my way of thinking to the point of realizing I needed to be part of the solution. I received my X-Waiver back in 2016 and started prescribing buprenorphine.

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Winnie: That’s a wonderful reflection on how repeated messaging helped change your mindset as a provider. It’s important to understand that people can change, no matter what holds them back.
 
Elisabeth: I think that as academic detailers, we might not always recognize the impact right away. We might not get the immediate positive feedback from a clinician after an interaction, but especially if you’re lucky enough to grow relationships with the people you detail over time, you can see the change. I think that’s the most effective and rewarding part of detailing.
 
I prescribe buprenorphine because I can teach about it, but I also do it because it’s important. This work gives us an opportunity to be leaders for people who don’t always have a voice, and because of stigma, aren’t being listened to. Most of our patients with OUD are on the margins and struggle even during stable economic times. Especially right now with the COVID-19 pandemic, the rest of the country may not be worrying about how we’re going to safely maintain our patients on buprenorphine, but we need to worry about it.

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Elisabeth Fowlie Mock, MD, MPH, FAAFP is a self-employed Family Physician consultant living in Holden, Maine.  She attended Vanderbilt Medical School and obtained a Master’s in Public Health at UNC-Chapel Hill.  She is a clinical educator for the Maine state Academic Detailing program (MICIS) and Alosa Health in Boston.  She is Board Certified in both Family Medicine and Addiction Medicine.  Her part-time clinical work includes evening shifts as a hospitalist and prescribing at a high-risk, low-barrier buprenorphine clinic.  She is passionate about women’s and girls’ basketball, travel, learning chess and singing.