Andrew B. Symons, MD, MS Denise McGuigan, MSEd Christopher P. Morley, PhD, MA, CAS Elie A. Akl, MD, PhD SUNY at Buffalo Department of Family Medicine and Medicine SUNY Upstate Medical University

Background  Evidence that early and frequent encounters with people with disabilities improve medical students' attitudes and comfort level regarding their care.  Few medical schools address disabilities and little attention has been devoted to the development of curricular content and strategies.

Rationale We developed and implemented a longitudinal curriculum to teach medical students to provide patient-centered care for people with disabilities.

Elements of the Curriculum Year 1 Clinical Skills Course: Lecture on disability and society followed by small- group encounters with people with disabilities and their families where they discuss aspects of their interactions with the health care system that have been helpful or hurtful. Year 2 Clinical Skills Course: Lecture on the challenges of the clinical encounter followed by a disability-related objective structured clinical encounter (OSCE) with people with disabilities and their caregivers. Year 3 Family Medicine Clerkship: Half-day workshop on the socioeconomic and legal context of caring for people with disabilities, and a one-day precepted clinical experience in a health care facility which provides primary care and integrated services for people with disabilities. Year 3 Internal Medicine Clerkship: Lecture on caring for people with disabilities - common medical concerns. Year 4Primary Care for People with Disabilities Electives

The objective of this study was to evaluate the effects of a curriculum on medical students’ self-reported attitudes and comfort level in caring for people with disabilities.

Methods Study Design: Pre/Post study design with comparison group. Setting: A baseline survey of self-reported attitude and comfort level working with people with disabilities was administered to first-year medical students in the clinical skills course taught at two regionally proximal and comparable medical schools in School A subsequently implemented the new curricular module, and School B maintained an existing curriculum.

Methods (continued)  In 2010, the same survey was administered to both cohorts in their third year of medical school (i.e. post-exposure to the curriculum for the intervention group)  Data were collected anonymously.

Instrument  5 point Likert-scaled instrument to measure students’ self-reported attitudes and comfort level toward people with disabilities.  The instrument was developed by:  adapting existing tools for assessing attitudes towards people with disabilities  input received from local professionals who work with people with disabilities, medical educators, patients and families.

Instrument (continued)  Demographics: age and gender  Personal and education experience with people with disabilities  18 attitude/opinion items related to people with disabilities  Reaction to two clinical vignettes

Instrument (continued)  Reaction to two clinical vignettes  One vignette portrayed an encounter with a patient without apparent disability accompanied by a companion.  The second vignette portrayed an encounter with a patient with an apparent disability accompanied by a companion.

Methods The initial survey results were used to establish equivalency between the intervention and control groups in terms of both demographics as well as baseline attitudes and comfort level.

Methods Statistical Analysis  Step 1: Do basic comparisons between items using  a) Chi-square (assuming responses to be categorical) and  b) simple ANOVA (assuming responses are ordinal and linear)  Step 2: Flag significant or near-significant differences. Re-test using General Linear Model (factorial ANOVA) to control for Gender and Age.  Step 3: Data reduction and regression  Reduce data via Principal Components Analysis (Factor Analysis)  Utilize factor loadings as dependent variables with course, gender, age as predictors  PCA/Factor Analysis serves as an additional instrument validation step

Results  Step 1 & 2: Significant differences favoring intervention (Strongly Disagree =1, Strongly Agree =4): Item Mean Int Mean Control p value: Χ 2 p value: ANOVA p value: GLM ( Case/Gender ) I am comfortable being around a person who has an intellectual disability (i.e. mental retardation, autism) /NS People with disabilities are as happy as people without disabilities /NS I am more comfortable around people with intellectual disabilities when they have someone who is not disabled to help them.* /NS

Results  Step 1 & 2: Near -significant differences favoring intervention (Strongly Disagree =1, Strongly Agree =4): Item Mean Int Mean Control p value: Χ 2 p value: ANOVA p value: GLM ( Case/Gender ) I would be comfortable interacting with a person with an intellectual disability who was in the community on his or her own (i.e., without staff members or caretakers) NS/NS If I were visited by a person who is blind, I would be comfortable helping him or her navigate the environment NS/NS I would be comfortable living in a neighborhood where there is a group home for people with various developmental disabilities (e.g., Down Syndrome, Cerebral Palsy, Mental Retardation, etc.) /NS

Results  Step 1 & 2: Significant differences favoring control group (Strongly Disagree =1, Strongly Agree =4): Item Mean Int Mean Control p value: Χ 2 p value: ANOVA p value: GLM ( Case/Gender ) Most people with disabilities feel sorry for themselves NS/0.004 Most people with disabilities resent people without disabilities /NS Most people with disabilities expect special treatment /0.014 (Course*Gender: p=.081)

Results  Step 3a: Factor Analysis- five factors identified (Principal Components Analysis, Eigenvalue ≥ 1, Varimax Rotation; Factor Loadings >.400 displayed) Agreement with Positive Statements  I would be comfortable being around a person who uses a wheelchair.  If I were visited by a person who is blind, I would be comfortable helping him or her navigate the environment.  I would feel comfortable living next door to a person with an intellectual disability that lives by himself.  I would be comfortable being around a person who is deaf.  I would be comfortable living in a neighborhood where there is a group home for people with various developmental disabilities (e.g., Down Syndrome, Cerebral Palsy, Mental Retardation, etc.).  I am comfortable being around a person who has an intellectual disability (i.e. mental retardation, autism).  I would be comfortable interacting with a person with an intellectual disability who was in the community on his or her own (i.e., without staff members or caretakers)  I would be comfortable working with a person with an intellectual disability who had someone assigned to supervise and train her.  I would feel comfortable being around a person with an intellectual disability in public even though his behavior might be a bit bizarre (e.g., rocking back and forth, loud, etc.). Agreement with Negative Statements  Most people with disabilities feel sorry for themselves  Most people with disabilities expect special treatment.  Most people with disabilities resent people without disabilities.  If I introduced a person with disabilities to my friends, I think they would feel uneasy.  I am only comfortable around people with intellectual disabilities if they are well- behaved.

Results  Step 3a Continued: Factor Analysis- five factors identified (Principal Components Analysis, Eigenvalue ≥ 1, Varimax Rotation; Factor Loadings >.400 displayed) Comfort with public behavior  Most people with disabilities are not ashamed of their disability.  People with disabilities should be cared for in any primary care office as opposed to a specialty clinic.  I would feel comfortable being around a person with an intellectual disability in public even though his behavior might be a bit bizarre (e.g., rocking back and forth, loud, etc.).  I would feel comfortable living next door to a person with an intellectual disability that lives by himself. Comfortable with behaved, assisted patients  I am more comfortable around people with intellectual disabilities when they have someone who is not disabled to help them.  I am only comfortable around people with intellectual disabilities if they are well-behaved. Primarily, reaction to Happiness  People with disabilities are as happy as people without disabilities.  I would be comfortable interacting with a person with an intellectual disability who was in the community on his or her own (i.e., without staff members or caretakers)  I am comfortable being around a person who has an intellectual disability (i.e. mental retardation, autism).

Results  Step 3b: Factor Scores utilized as dependent variables in Stepwise Linear Regression.  Two Models emerged as significant:  Agreement with Negative Statements (R 2.127, Model Sig <.001)  Primarily, Reaction to Happiness (R 2.065, Model Sig =.003) PredictorBetap-value Male I have had experiences similar to scenario B (Scenario involving a disabled patient) PredictorBetap-value I have had experiences similar to scenario B (Scenario involving a disabled patient)

Conclusions  Intervention led to a significant or near-significant improvement in several factors  Intervention group appeared to also produce a small cohort of those who felt patients with disabilities were more resentful, looked for special treatment, felt sorry for themselves  On more sophisticated analyses, effect was revealed to be due in large part to Gender, with Males being more likely to endorse such views, as well as experience.  Experience may reinforce negative views in male students?  Factor analysis reveals items to be grouping in coherent, theoretically predictable ways, indicating further validity for the instrument.

Conclusions The positive impact of this curriculum supports inclusion of elements of the curriculum in other medical school programs if we are to improve care provided for people with disabilities. Caution advised! There may be a  creation of new, or  reinforcement of existing negative views based upon experience, especially in male students. Further investigation of the male/experience issue is warranted.