Conversation Café: Changing the Culture of Addiction Medicine

Allan's Glaswegian accent is so thick that I'm pressing my phone into my ear and turning around looking for someone to tell to be quiet so I can hear him better. 'Reit, wit serta taime scael ye thankin?' he asks, bluntly, pressing me to figure out if I’m serious about setting up a regular meeting for medical students to connect with people in recovery from drug and alcohol addiction. I answer honestly, saying that I don't really know. 'Reit, well just cam alang tae the meetin in knightswood tomorra and we'll talk'.  It's 2021, and I'm a 23 year-old 3rd year medical student walking through Glasgow's botanic gardens. The trees are burning gold in the late-autumn sun and I'm planning a new project for Humanising Healthcare, a medical community I'd recently set up for grass-roots change in medical education. The year before, I had found myself in a Narcotics Anonymous meeting in Dundee in support of a friend. I was transformed by the experience, realising how wrong my understanding of addiction was, and the importance of knowing that long-term sustainable solutions to addiction existed in the community. What kept me interested was that the process of recovery seemed to revolve around self-understanding, relationships, community and finding meaning in life. It was the kind of personal and community healing culture I had hoped to be taught in medical school, but any peep of that holistic approach was crushed by the DSM5, the 1220 page tome of psychiatric diagnostic criteria which our exams were based on. 

He spots me from a mile off, a scruffy wind-swept student in doc martens coming through the door of the community centre in North West Glasgow. Although abstinent for 31 years, his tattooed hands are permanently swollen and thrombosed with little worm-like veins from his years of injecting heroin. The stereotype of a hardened drug user and all the stigma that comes with it is obliterated by the huge smile he greets me with, as has been the case for every person in recovery that I’d met before and since.

This was the beginning of a now three year long friendship and working relationship with Allan, who is a senior addictions worker for Glasgow's Alcohol and Drug Recovery Services. He now helps other people with their journey. Together with Seonaid Anderson (a consultant addictions psychiatrist who would join the project the following year), we are changing medical culture around addictions medicine through our co-created project: Conversation Café. 

After that first meeting in Knightswood we set up regular 'medics’ nights' at the Scottish Recovery Consortium's premises to bring the two groups together. We ran discussion groups, creative writing groups and even tried two-way simulation of clinical scenarios where Lived Experienced community members were able to act the doctor and the students acted the patient! 

The benefit of involving people with Lived Experience of addiction and recovery in medical education was instantly obvious. One of my friends left with tears in her eyes saying that she had learnt more about addiction in one and a half hours than in 5 years of medical school. It seemed that the opportunity to connect with people outside of a clinical setting, and to hear their authentic stories created an immensely powerful learning environment that traditional lectures or simulation couldn't touch. However, out of 1500 students, all of whom were sent a bulletin about our sessions, only 10 or so ever turned up. This poor engagement was probably due to a combination of the offensively cold winter nights and typical medical school stressors making students blur out anything that isn’t examinable.

Whatever the case, Allan and I knew that we were onto something important, so we wondered: 'if the students wouldn't come to the community, would the community come to the students?' That spring, as the longer days brought hope and the grey of winter was banished by the annual city-wide explosion of candy-floss pink and white blossom, we met regularly in cafe's around Glasgow. Countless cappuccinos were consumed whilst we devised the 'Conversation Café'. This was the first version of the ‘one-off’ session we would approach medical schools with. 

The Conversation Café is incredibly simple yet remarkably powerful. It involves inviting people with lived experience of addiction and recovery into medical schools for a 2-hour session of small-group round table discussions using question prompts carefully designed to guide the conversations towards important themes of recovery. The session begins with a 15 minute monologue 'share' of someone’s lived experience, and then the Conversation Café begins with 10 minutes for each question prompt. At the end of each discussion, students get up and move around to the next table, a bit like speed dating but for talking about addiction. Things get written down on post-it notes and stuck on walls, and there’s always loads to eat. It’s a good time. 

The first trial was endorsed by Glasgow medical school, but attendance was still optional. About 30 people from the community showed up, which was the first time in history that ex-drug users had crossed the sliding doors of a pristine modern medical school en-masse. For them this was an important event. They had been through the trauma of addiction and survived, and they wanted to share their stories of hope and success with the future generation of doctors so they could learn how to help their patients in similar situations. One of them even came in a suit and tie. Allan and his community team got to work immediately, transforming the clinical skills area into a pop up cafe, bluetooth speaker blaring out tunes from a chair next to a model skeleton and plastic bum for practising prostate exams. Darren McGarvey, author, rapper and political critic, attended to share his experience of addiction and recovery in his characteristic raw delivery: “GPs handed out anti-depressants like they were tic tacs”, he recalled.

To our delight, feedback from these students revealed the same transformational effect that I had felt on my first contact with people with lived experience: 

"This session was better than any lecture I've had. Speaking with people going through recovery is eye-opening and very much has changed my views on how as a future professional I can help."  - said one 2nd year medical student in Glasgow.

The Conversation Café had worked, but there was a sting of disappointment: out of the 20 students that signed up via the online form, only 10 turned up - an embarrassing 50% attrition rate. I was mortified that the community had been let down by students who probably just decided it wasn’t worth the effort. So, again, we found that when optional, attendance is poor, but for those that do come it is powerful and potentially transformative.

In order to get more students there, we needed to get a foot in the door with a medical school who would consider it as a curriculum event. Glasgow wasn't forthcoming to make that happen as it was struggling to accommodate for the ever-expanding 400 + student year group. As a student / social worker duo, Allan and I had little power to sway the big dogs of the medical schools. We were stuck and our out-reach emails were being lost into the bureaucratic echo-chamber. Then, with perfect timing, Dr Seonaid Anderson, a consultant addictions psychiatrist and clinical lecturer, reached out saying that she had heard of the project and wanted to trial it at the University of Dundee. They had agreed to mandate attendance for a group of their students in the psychiatry block, eliminating any selection bias in feedback.

Scotland has the highest drug related death rate in Europe, but at the same time there are active communities around the country working together to sustain new lives. We contacted the already-galvanised community in Dundee and with surprisingly little effort, we ran two sessions in October 2022. We drew a breath of excitement and relief when we saw the feedback forms, almost all of which had circled 10's for the perceived benefit of the session, and with the same superlative qualitative feedback. The only negative feedback we had was for more time. Imagine that: students (!) asking for a longer (than 2 hour) session! The effect was indeed proving to be universal, and this was transforming the way students thought about addiction and how to help patients they may see in the future. 

'We never get opportunities like this, and I think it is so important for making us aware and better understanding of patients we may see in the future. Experiencing this will make us better doctors. ' - said one 3rd year medical student from Dundee

Since then, Humanising Healthcare's Conversation Café has gone from strength to strength and is blazing the way to a culture shift in addictions medicine. The Scottish Government, who are aware of the importance of Lived Experience in informing policy on drug use and recovery services, have supported and endorsed the project. They see it as a tool to develop the future workforce. Over 300 students across four out of the five medical schools in the country have now benefitted from the session, with evidence showing that the future generation of doctors who have experienced a cafe will have more empathy for people with addictions and greater understanding about how to provide effective care using social prescribing into community recovery groups. Three years after the project's inception, the University of Glasgow has agreed to run it in their curriculum this academic year, and Dundee have also implemented it as a core part of their psychiatry curriculum. We also know that the effect is not limited to medical students; 100% of qualified GP attendees reported that the session changed the way they would approach treating patients with addictions in the future. One of them even said: 'I wish I had had this 25 years ago when I first qualified'. 

We hope to expand the project further, and will look to the rest of the UK and even internationally once fully established in Scotland. We owe the success of the project to the inspiring recovery communities, and I personally have so much to thank them for. They kept me motivated throughout medical school by reminding me that love and spirituality are so important in the healing process when I was only being taught diagnosis, drugs and surgery. Recovery is an example of changing deeply rooted behaviours to create health and happiness. We know that the recovery community loves coming to the Conversation Café and we continually see feedback forms come back with things like 'it's so important that our stories are heard'.

The Greek 'Krisis', from which our 'crisis' is derived, meant 'decision' or 'turning point'. The Conversation Café shows future doctors how a true 'krisis' can be transformational if the person is held by a community committed to supporting the decision to change.  Over 1200 people died of drug addiction last year in Scotland and many more from complications related to drugs and alcohol.  This is a rare example of progressive and rapid culture change being driven by policy makers. The Scottish Government have accepted that the old ways of punishment and demonisation arent working, so instead they are facing into this krisis. Their support of the Conversation Café and other recovery community organisations is a decision to approach things differently by and tapping into the wisdom of people who have lived the journey of addiction and recovery. Like so many areas of medicine and medical education where students are being let down by myopic curricula, out there in the community there are effective solutions to be found.

To get involved in the project or to explore setting up a Conversation Café at your institution, get in touch via: humanisinghealthcare@gmail.com