Caring for disabled adults: assessment of a Family Medicine curriculum Rachel S. Brown, MD Assistant Professor Department of Family and Preventive Medicine University of South Carolina School of Medicine

Barriers to Care Transportation Transportation Provider bias Provider bias Provider ignorance Provider ignorance Provider and patient discomfort Provider and patient discomfort Poor availability of resources Poor availability of resources The Healthy People 2010 initiative and the 2005 ADA “Call to Action” recognized that patients with disabilities are vulnerable to substandard care.

Medical Education on Patients with Disabilities University of South Carolina School of Medicine, Columbia University of South Carolina School of Medicine, Columbia University of Medicine and Dentistry of New Jersey, Newark University of Medicine and Dentistry of New Jersey, Newark Tufts University School of Medicine, Boston Tufts University School of Medicine, Boston University of South Florida College of Medicine, Tampa University of South Florida College of Medicine, Tampa University of Illinois— Chicago College of Medicine University of Illinois— Chicago College of Medicine University of Pennsylvania School of Medicine, Philadelphia University of Pennsylvania School of Medicine, Philadelphia University of Massachusetts Medical School, Worcester University of Massachusetts Medical School, Worcester University of North Carolina School of Medicine, Chapel Hill University of North Carolina School of Medicine, Chapel Hill

Value of Learning Experience Fosters a trusting and respectful patient- physician relationship Fosters a trusting and respectful patient- physician relationship Teaches providers to seek ways to adapt care to patients’ unique daily needs Teaches providers to seek ways to adapt care to patients’ unique daily needs Encourages providers to recognize their patients’ desire for a healthy quality of life Encourages providers to recognize their patients’ desire for a healthy quality of life Approximately 54 million Americans live with a disability!

Is there a lasting impact of the Family and Preventive Medicine curriculum related to adults with disabilities on medical students’ attitudes, behaviors, and knowledge?

Curriculum and Evaluation Components Didactic in preclinical years Didactic in preclinical years Didactic & panel discussion during clerkship Didactic & panel discussion during clerkship Clinical exposure in FM clinic & Babcock Centers Clinical exposure in FM clinic & Babcock Centers Student survey Student survey Observed Structured Clinical Exams (OSCEs) with standardized patients Observed Structured Clinical Exams (OSCEs) with standardized patients

Survey Design Adapted from *Canadian Attitudes Towards Disability Issues used by the Canadian government Adapted from *Canadian Attitudes Towards Disability Issues used by the Canadian government Administered on three occasions: Administered on three occasions: –During second year didactic –Before FM clerkship –At completion of FM clerkship Assesses students’ knowledge and attitudes Assesses students’ knowledge and attitudes *Environics Research Group, 2004

OSCE Development Trained two groups of standardized patients Trained two groups of standardized patients –Pts with spinal cord injury –Pts with cognitive impairment & their caregivers Scenarios written for common health issues other than the disability itself Scenarios written for common health issues other than the disability itself –Diabetes and fatigue –Hypertension Assesses students’ behavior (& knowledge) Assesses students’ behavior (& knowledge)

Survey Results Results compare 60 pre & post-rotation survey answers. Results compare 60 pre & post-rotation survey answers. Fewer students felt awkward with or sorry for pts after the classes. Fewer students felt awkward with or sorry for pts after the classes. Most students knew of the ADA laws at baseline. Most students knew of the ADA laws at baseline. We identified a weakness in teaching students how to handle SCI pt transfer. We identified a weakness in teaching students how to handle SCI pt transfer. Students learned that MR pts were concrete thinkers after intervention. Students learned that MR pts were concrete thinkers after intervention. CHARACTERISTIC P-VALUE FOR CHANGE Student felt awkward with pts < Student felt sorry for pts < Students were aware of ADA laws 0.34 Students could properly address SCI pt transfer 0.50 Students recognized MR pt concrete thinking <0.001

OSCE Results Average score on SP OSCEs Average score on SP OSCEs –Determined by percentage of items on OSCE checklist completed Pts with MR: Pts with MR: Pts with SCI: Pts with SCI: Non-MR and SCI scenarios: Non-MR and SCI scenarios: Implies Implies

Limitations to Study Student bias in filling out survey Student bias in filling out survey Student communication about the OSCEs Student communication about the OSCEs Intra-rater variability Intra-rater variability Inter-rater variability Inter-rater variability –Video review

Challenges to Developing Curriculum Limited didactic time in an already full curriculum Limited didactic time in an already full curriculum Availability of willing and responsible standardized patients Availability of willing and responsible standardized patients Cost and time of training and utilization of standardized patients Cost and time of training and utilization of standardized patients Logistical complications of doing numerous standardized patient OSCEs Logistical complications of doing numerous standardized patient OSCEs

Curriculum Evaluation Focus groups Focus groups survey survey Evaluation forms Evaluation forms Quotes here

Future Plans Additional scenarios Additional scenarios Patients with other disabilities Patients with other disabilities Assessment of practicing physicians’ perspectives on the importance of this type of training Assessment of practicing physicians’ perspectives on the importance of this type of training

References Department of Health and Human Services. The Surgeon General’s call to action to improve the health and wellness of persons with disabilities. Rockville, MD. Public Health Service, Department of Health and Human Services. The Surgeon General’s call to action to improve the health and wellness of persons with disabilities. Rockville, MD. Public Health Service, Department of Health and Human Services. Healthy People 2010: understanding and improving health; objective for improving health. 2 nd ed. Washington, DC. Government Printing Office, November Department of Health and Human Services. Healthy People 2010: understanding and improving health; objective for improving health. 2 nd ed. Washington, DC. Government Printing Office, November Going beyond Disease to Address Disability. Iezzoni, Lisa I. New England Journal of Medicine, Volume 355 (10), September 2006, pp Going beyond Disease to Address Disability. Iezzoni, Lisa I. New England Journal of Medicine, Volume 355 (10), September 2006, pp