desired educational outcomes of disability- related training for the generalist physician:...

Disabilities Medicine Education

Desired Educational Outcomes of Disability-Related Training for the Generalist Physician:Knowledge, Attitudes, and SkillsPaula M. Minihan, PhD, MPH, Kenneth L. Robey, PhD, Linda M. Long-Bellil, PhD, JD,Catherine L. Graham, MEBME, Joan Earle Hahn, PhD, Laurie Woodard, MD, andGary E. Eddey, MD, on behalf of the Alliance for Disability in Health Care Education

Abstract

The problems adults with disabilities faceobtaining quality primary care servicesare persistent and undermine nationalefforts to improve the health status ofthis group. Efforts to address this issueby providing disability-related training tophysicians are hampered by limitedinformation about what generalistphysicians need to know to care forpatients with disabilities. The authorsconsider the desired outcomes ofdisability-related training for generalistsby exploring the contributions of thedomains of knowledge, attitudes, and

skills to patient-directed behavior andsummarizing the empirical data.

Because disability reflects a complexinterplay among individual, interpersonal,institutional, community, and societalfactors, generalist physicians can promoteand protect the health of adults withdisabilities by interventions at multiplelevels. Thus, the authors use the social-ecological framework, an approach tohealth promotion that recognizes thecomplex relationships between individualsand their environments, to delineate the

recommended knowledge, attitudes, andskills in the context of primary care. Theimportance of role models whodemonstrate the three domains, theinteractions among them, and issues inevaluation are also discussed. This cleardelineation of the recommendededucational outcomes of disability-relatedtraining in terms of knowledge, attitudes,and skills will support efforts to betterprepare generalist physiciansin trainingand in practiceto care for adults withdisabilities and to evaluate these trainingstrategies.

Editors Note: A commentary on this article appears

on page 1069.

Quality primary care is a criticallinchpin in efforts to improve the healthstatus of persons with disabilities (PWDs)and is a national goal articulated inHealthy People 2010.1 The problemsPWDs face finding and accessing primarycare services, first formally recognized asa deficiency in the health care system in1989,2 persist to this day.35 Providingdisability-related training to physicians inthe adult generalist specialties (i.e., familymedicine and general internal medicine)is essential to support these physiciansefforts to manage the care of patientswith disabilities, but there is limitedinformation about what generalistphysicians need to know to guide traininginitiatives.

For adults with disabilities, problemshave been reported at multiple levels ofthe primary care experience. Theseinclude problems at the level of themedical interview itself, such as failuresin communication that interfere withmedical history taking, compromisepatients understanding of treatmentregimens and risks, and detract frompatient satisfaction618; inattention topatients concerns about maintainingdaily activities11; and difficultiesaccommodating patients who requiremore time for office visits.2,11,12,17 It alsoincludes accessibility and attitudinalbarriers that interfere with the timelyprovision and completeness of physicalexaminations, diagnostic procedures,and screening and preventiveservices,2,8,9,12,18,19 and practice operationsthat fail to anticipate and prepare fordisability-related issues in advance ofvisits.17,18 Problems with the delivery andfinancing of health care servicesnationwide exacerbate the challengesgeneralist physicians face in meeting theneeds of adults with disabilities.20

Generalist physicians caring for childrenwith disabilities face similar challenges,but they generally derive support fromthe organized network of services in placefor children with disabilities throughschool systems and more robust health

insurance benefits. The network ofservices and supports in place to promotethe health of children with disabilities isnot available to adults with disabilities ortheir physicians.

In this article, we use Blooms21

taxonomy to explore the desirededucational outcomes of disability-related training in the pursuit of anoptimal primary care experience foradults with disabilities. Bloomstaxonomy refers to a framework forunderstanding and conceptualizing therealms of educational outcomes based onthree domains: cognitive (knowledge),affective (attitudes and values), andpsychomotor (skills). This framework isused widely in the health care educationliterature, including studies andcommentaries focused on disability-related training.2228 A clearer delineationof desired disability-related trainingoutcomes is essential to efforts to betterprepare generalist physicians to care foradults with a range of disabilitiescongenital or acquired; physical,intellectual, or psychiatricand toevaluate training strategies for doing so.This article is based on the literature andon our own experiences teaching medicalstudents about the needs of patients withdisabilities. Our group, the Alliance for

Please see the end of this article for informationabout the authors.

Correspondence should be addressed to Dr.Minihan, Department of Public Health andCommunity Medicine, Tufts University School ofMedicine, 136 Harrison Ave., Boston, MA 02111;telephone: (617) 636-2461; e-mail:[email protected].

Acad Med. 2011;86:11711178.First published online July 21, 2011doi: 10.1097/ACM.0b013e3182264a25

Academic Medicine, Vol. 86, No. 9 / September 2011 1171

Disability in Health Care Education,includes medical educators and otherhealth professions educators, some ofwhom bring their personal andprofessional experiences living withdisability to this discussion, includingtheir experiences as primary carepatients.

Background

Definition of disability

In our work, we use Iezzonis11(p977)

definition of disability: difficultyperforming daily activities and fulfillingsocial roles because of physical, sensory,emotional, or cognitive impairment,often compounded by environmentalbarriers. This definition combines theessence of the biomedical definition ofdisability with the more contemporarysocial model. The former emphasizespersonal characteristics, such as medicalconditions and impairments, and theneed to fix them. The latter considers anindividuals ability to function in thepresence of an impairment to bedetermined largely by his or her physicaland social environment, and seeks tooptimize individual functioning bychanges at the institutional, community,and societal levels. Ones definition ofdisability influences the knowledge,attitudes, and skills that are viewed asprerequisites for the optimal care ofpatients with disabilities. The perspectiveon disability that generalist physicianshold may influence how patients withdisabilities view their physicians and,ultimately, those patients perceptions ofthe acceptability of the care they receive.

Meeting the primary care needs ofpersons with disabilities

PWDs have the same needs for clinicalprevention and health promotionservices, acute care, and care for commonchronic conditions as persons withoutdisabilities.20,29 Some PWDs have specialneeds that are specific to their primaryimpairment or medical condition or thatreflect a thinner margin of health20,30

and make them susceptible topreventable secondary conditions andmedical complications.20,29,31 Some alsoface health risks because it is moredifficult to engage in healthy behaviors,such as regular physical activity andhealthful diets.20 Healthy lifestyles areparticularly important now that manymore PWDs live to average life spans,

increasing their risk for common chronicconditions associated with the agingprocess as well as with their primaryconditions.31,32

Most medical educators agree thattechnical competence is a necessarycomponent of what the generalistphysician should know about patientswith disabilities, but technical skills aloneare not sufficient to provide high-qualityprimary care to PWDs.33,34 In two coredisability curricula designed for medicalschools in Australia26 and Britain,35 agreater number of attitudinal topic areaswere deemed essential than were topicareas related to knowledge or skills. Morerecently, Kirschner and Curry36 proposedsix core competency areas to guide thedevelopment of disability-relatedlearning objectives in health professionscurricula. These core competenciesemphasize the acquisition of knowledgeand skills.

Desired Educational Outcomes

The social definition of disability reflectsa complex interplay between theindividual and his or her social andphysical environment. Because efforts topromote and protect the health of PWDsare optimally approached from thecombined social and physical perspective,we use the social-ecological framework toconsider the knowledge, attitudes, andskills that generalist physicians shouldpossess to care for patients withdisabilities.37 The social-ecologicalframework is a health planning modelthat is predicated on the belief thatoptimal health reflects individual,interpersonal, organizational,community, and public policy influences.

It fits well with the social definition ofdisability, and may be useful tophysicians who are unfamiliar with thisdefinition. See Figure 1 for an illustrationof this framework.

This framework assumes that generalistphysicians have the potential to optimizethe health status of patients withdisabilities through interventions atmultiple levels, but that doing so requiresnot only knowledge but also appropriateattitudes and skills.

Knowledge

Within medical education, knowledgeencompasses the sciences fundamental tomedical practice and their clinicalapplications and is evaluated by the UnitedStates Medical Licensing Examination(USMLE).38 It is encouraging that thecontent descriptions for USMLE Step 1(basic science knowledge) and USMLE Step2 CK (clinical knowledge) listdevelopmental disabilities and otherdisability-related content, respectively.

Empirical data describing what healthproviders know about the care of patientswith disabilities are limited, althoughevidence suggests that a lack of knowledgeis a problem.20,36,3944 For the purpose ofthis discussion, we include the issuespresented in List 1 within the realm ofknowledge.

Although knowledge provides a foundationon which to build an understanding ofproblematic issues and for the developmentof solutions to those issues, research hasshown that enhancing knowledge is notsufficient for influencing behavior.45 If ourend goal is to influence the behaviors ofgeneralist physicians in training and in

Community Physical and social accommodations to promote

participation

Public Policies, Laws, RegulationsPublicly-financed health insurance, income support, para-transit,

Americans with Disabilities Act

OrganizationsPolicies and procedures in health care sites and among insurers to promote health, including adjustments and

accommodations in environments and equipment

InterpersonalSupport from physicians, staff, family, friends,

personal care attendants to facilitate interactions

Patient with a DisabilityHis or her knowledge and

experience

Figure 1 Factors influencing the health of patients with disabilities.


Academic Medicine, Vol. 86, No. 9 / September 20111172

practice, didactic instruction aimed atimparting knowledge is a necessary butperhaps insufficient modality. Fortunately,medical education is not concerned solelywith imparting knowledge.

Attitudes

Studies have examined various healthprofessions students attitudes regardingdisability following disability-related

educational interventions.8,4652

Generally, these studies report that,without intervention, student attitudestoward PWDs do not support positivepatientprovider interactions, albeit withsome exceptions.22 Studies regarding thequality of life of PWDs report widevariations in the attitudes reported byphysicians compared with the attitudes ofPWDs.17,23 Research has demonstrated

that direct and positive exposure to adisfavored or marginalized group (i.e.,exposure in which members of thatgroup are viewed as capable, likable, etc.)increases positive attitudes toward thatgroup. Recent research suggests that thesepositive exposures can favorably influenceeven those deeply entrenched and implicit(i.e., unconscious) biases that aresometimes assumed to be intractable.53

This suggests that training programs, inorder to substantially affect deeply heldattitudes toward PWDs, should includesubstantial positive contact with suchpersons. Such positive exposure is found insome existing programs.8,22,52,54

Such contact should not be limited onlyto courses focusing on the interpersonalaspect of medicine. In one study, medicalstudents who were asked for suggestionsabout disability-related training viewedthe presence of PWDs in hard sciencecourses, where they discussed physiologicalaspects of their conditions and the impacton their lives, as providing compelling andmemorable lessons.15 In contrast, thesestudents felt that adding disability asanother patient attribute deservingempathy to courses viewed as touchyfeely may hinder rather than helpawareness of disability-related issues,perhaps reflecting what might be a broaderlack of appreciation for courses intended topromote humanistic practice. It is worthnoting, however, that these same studentsreported that such courses proved valuablelater in their education as they beganlearning to take histories and conductphysical examinations. These studentspreferred interacting with real patients toexercises where students themselves wereasked to simulate the experience of having adisability (i.e., through use of a wheelchair,blindfolds, etc.)55; others have foundsimulation exercises to be valuable.34,39 It isalso possible to incorporate more ongoingcontact with PWDs through home visits,following specific patients, and otherapproaches.39 We propose including theelements in List 2 within the attitudinaldomain.

Skills

For the purpose of this discussion, skillsare defined as technical or socialcompetencies that are reflected inobservable actions. Studies evaluatingphysicians skills with patients withdisabilities seem limited and focusedlargely on the effectiveness of their

List 1Knowledge Components of Disability-Related Generalist Training*

Components Related to Patients With DisabilitiesOne should:

Be familiar with primary disabling conditions and their associated medical conditions.

Acknowledge narrow margins of health resulting in secondary conditions and other medicalcomplications.20,30

Be familiar with medications beyond the scope of primary care practice.19

Be familiar with functional limitations with specific disabilities.19,35

Be aware of potential earlier onset of common chronic conditions.20

Be aware of additional functional limitations associated with common chronic conditions.20

Be aware of the availability of age, gender, and disability-specific preventive health careguidelines.

Be familiar with equipment and aids to maintain or increase individual functioning, andassociated prescriptions.20,24,58

Understand the physicians role in determining medical necessity for services andequipment.20

Recognize the patient as an important source of information.11,24

Interpersonal ComponentsOne should:

Be aware of appropriate and preferred language to include person first language.

Be familiar with alternative communication methods with a patient, for example, pictureboards, writing, sign language interpreters, etc.

Be knowledgeable about alternative positioning needs during physical exams.75

Understand alternative communication methods between office staff and patients, for example,for phone communication with patients who are deaf.14,17,18

Be able to recognize accessibility issues impacting patients ability to interact with the practiceand physician, for example, physically accessible exam tables, mammography machines, scales,and parking/building for patients with mobility limitations.

Understand the need for interdisciplinary care approaches for people with disabilities.76

Understand and be cognizant of the effects of disability on family relationships andfunctioning.19

Understand the benefits of empowering patients with disabilities in their relationships withphysicians.23

Societal ComponentsOne should:

Understand the social context of disability, including social and biomedical models, anddefinitions of disability.

Be familiar with legal requirements applicable to health care, including the Americans withDisabilities Act.42,75

Identify available services to support health and wellness.4

Be familiar with the social service system and health care financing issues.20,23,39

Fully understand legal and consent issues when patients have cognitive disabilities.77

Be aware of the effects of disability on education, mobility, employment opportunities andcommunity participation.24

* The information in this list reflects the literature as well as the authors own experiences teaching medicalstudents about the needs of patients with disabilities and living with disability.



communication skills; findings suggestdeficiencies in this area.14 Skills tocommunicate effectively with PWDs arehigh on the lists of requisite disability-related competencies generated by healthprofession educators.6,8,9,14,16,17,40,54,56,57

Another important skill is the assessmentof a patients level of functioning. Thisskill enables a physician to establish abaseline for the tracking of progressiveimpairments (or identifying the presenceof associated or secondary conditions),predicting prognoses and planninginterventions, such as referral to physicaltherapy or for assistive devices such as awheelchair.58 In addition, the assessmentof function can be useful foradministrative purposes, including thosethat are intrinsic to medical treatment,such as documenting the need for certainservices,58 and those that may assist theindividual in obtaining needed resources,such as Social Security benefits ormedical assistance. We do not know ofany studies evaluating physicians skills inassessing the functional levels of patientswith disabilities. We propose theelements in List 3 to be within the realmof requisite skills.

The importance of role models

Although didactic presentation ofinformation is helpful in the developmentof some of these skills, additional directdemonstration and practice are likelynecessary. Physician shadowing or clinic-based experiences that involve observedand/or direct contact with patients, orstandardized patient exercises in whichskill-related challenges are presented in acontrolled context, are critical.59 Inaddition, senior andmore experiencedphysicians are important sources ofinfluence for students and earlypractitioners by transmitting knowledgeand demonstrating attitudes and skills. Tothe extent that they display appropriatecompetencies when treating patients withdisabilities, they can be powerful agents ofchange.

Knowledge, attitudes, and skills asinteracting dimensions

Knowledge, attitudes, and skills do notact independently. A training programmight contribute a skill, such as theability to position a patient with aphysical disability for a physicalexamination, to a students toolkit.

That skill will only be put into practice,however, in the presence of attitudes thatprompt the student to use it. Similarly, atraining programmight impart knowledge,such as the array of conditions associatedwith a primary disabling condition, but thatknowledge will not be useful without well-practiced skills in clinical interviewing orphysical examination with patients withdisabilities. Students and physiciansawareness of their lack of knowledge andskills necessary to work with patients withdisabilities is associated with discomfort19,23

andmay perhaps be one source of negativeattitudes toward such patients.

Evaluation of Disability-RelatedTraining

In any educational endeavor, themeasurement of educational outcomes isnecessary to ensure that the impact oftraining is well understood and that thisinformation is used to improve theintervention. Strategies exist within eachof Blooms educational domains tomeasure the outcomes of disability-related training, although the applicationof these strategies is in its infancy.

Knowledge.Written or oral assessmentof the attainment and retention ofinformation is an appropriate strategy tomeasure learner knowledge gain. Oneexample here might be the use of awritten test to assess studentsunderstanding of associated medicalconditions that commonly accompanyprimary disabling conditions, or of laws,regulations, and policies concerningavailability and accessibility of health carefor PWDs. Knowledge can also beassessed through observation of practicalapplication of information gained as thestudent encounters patients in real orsimulated clinical situations.

Attitudes. The measurement of attitudechange, although often used in evaluatingtraining regarding special populations orthose in which health disparities exist,might be somewhat less straightforward.Although there are scales designed tomeasure the attitudes of other medicalprofessionals,60,61 there is currentlyno known validated scale designedspecifically for measuring the attitudes ofmedical students toward PWDs.62 Manyof the validated scales available are eitherquite dated6367 or measure relativelybroad attitudes toward PWDs, with their

List 2Attitudinal Components of Disability-Related Generalist Training*


Accept that some people with disabilities may approach encounters with fear or mistrustbecause of previous negative experiences with physicians.

Appreciate the importance people with disabilities place on preserving function and maintainingtheir lifestyles.11


Recognize ones own attitudes toward people with disabilities, including emotions, values, andimpact on practice.11

Identify institutional attitudes, including practice-specific attitudes, and how they influenceaccessibility and care.

Recognize that patients disabilities are one of many dimensions of their health.13,18,26

Support partnerships with patients and respect patient autonomy.19,39

Support caregivers, both paid and family.35

Acknowledge interdisciplinary team approaches and the contributions of different healthprofessionals.

Recognize the sexuality and reproductive health of people with disabilities.35

Build administrative systems with a capacity to anticipate and plan ahead for disability-relatedneeds.17


Consider societal attitudes toward people with disabilities and how these shape values,language, personal attitudes, and how people with disabilities feel.23,35




direct applicability to physiciansattitudes toward their patients not clearlyestablished.68,69 A more vexing problemwith attitude measurement is thetendency to respond to attitude scaleitems in the way that the respondentperceives is expected by faculty, or basedon differences between consciouslyrecognized attitudes and thoseunrecognized attitudes that also drivebehavior. Tests of implicit (i.e.,unconscious) attitudes are intended toaddress these problems in attitudemeasurement, and implicit tests ofattitudes regarding disability have beenoffered,70 including one that assesseshealth care workers unconsciousattitudes toward patients withdevelopmental disabilities.71 Theirreliability and validity as measures ofattitude change, however, are not yetfully established.

Skills. A students attainment of skills canbe measured through direct observationof the students performance in eitherreal or simulated encounters withpatients (e.g., OSCEs). This wouldinclude such activities as conducting amedical history72 or going through thesequence of steps to transfer a patientfrom a wheelchair to an examinationtable.

Behavioral change in practice. Inevaluating efforts to teach medicalstudents and physicians in training aboutdisability, it is important to assessprogress toward the end goal: change inactual behaviors toward patients withdisabilities that last into the studentsprofessional life. Some interventionsintended to influence the behavior ofphysicians toward patients withdisabilities might show some impact in

the short term but without lastingeffects.73 It is much easier to evaluatechanges in behaviors following adisability-related educationalintervention while the student is enrolledin the training program and is, if not acaptive audience, at least easilyaccessible.74 Changes in behavior can bestudied in a controlled context (such as astandardized patient),8,42,74 or they canpotentially be studied in the context ofsupervised practice, such as duringrotations or internships. Evaluation ofthe long-term impact of disability-relatedtraining among practicing professionals isgenerally not available. Nonetheless,avenues of assessing longer-term impacton behaviors in posttraining professionalpractice must be pursued.

Educating Physicians for theBenefit of All Patients

It is important that adults withdisabilities each have at least onephysician who focuses on the wholepatient within the context of an ongoing,long-term relationship. In mostsituations, this physician would practice ageneralist specialty, optimally working incoordination with subspecialty physiciansand allied health professionals who mightalso be involved with the patients care,yet such coordination presents logisticaland financial challenges, in addition tothe challenges inherent in the directprovision of care.

For adults with disabilities, practicesupports can be particularly effective.However, the lack of universal educationrequirements and uncertainty about thedesired outcomes of disability-relatedtraining in the context of primary caremay inhibit support for traininginitiatives designed to support qualityprimary care for PWDs. Lack ofknowledge about the universe of practicesupports for patients with disabilities andtheir potential impact on patient caremay similarly hamper support forpractice support provisions. Theknowledge, attitudes, and skillsframework we have proposedencompasses both training and practicesupport elements.

Under current, less-than-idealcircumstances, we believe that disability-related training is appropriate at all levelsof health care education and practice andsuggest that, given the historical lack of

List 3Skill Components of Disability-Related Generalist Training*


Be able to look beyond the patients disability and recognize unrelated acute and chronic careissues.20

Prevent or minimize comorbid conditions associated with some disabilities via vigilant healthmaintenance strategies and timely interventions.20

Address health promotion, clinical prevention, and screening issues according to needs, age,gender, and disability-related guidelines.

Be able to assess the patients level of functioning.58


Use proper etiquette (e.g., shake hands even when hand is immobile, sit at eye level, announcepresence when patient is blind).78

Ask patients about their preferred method of communication, use preferred vocabularyregarding disability, use alternate interviewing strategies (such as the use of yes/noquestioning).14

Be aware of and support the use of manual and electronic communication devices andAmerican Sign Language interpreter services.14

Use proper positioning techniques to provide adequate physical examinations and comfortableand safe experiences for patients.13,40

Partner with patients with disabilities to ensure treatment recommendations are accessible,acceptable, and doable.

Manage the clinical interview to ensure patient participation when a caregiver or family memberis involved.

Promote interdisciplinary or collaborative practice.19,79

Facilitate the transition of youth with disabilities into adult services.

Advocate for resources for people with disabilities, including ability to demonstrate medicalnecessity in requests to insurers.


Identify and advocate for policy, practice, and systems changes needed to provide optimalhealth supports and services for people with disabilities.80




such training, even residents and themost seasoned generalist physicians couldbenefit from exposure to the most basicinformation (knowledge), to positiveinteractions with persons who havedisabilities (attitudes), and to theopportunities to become more proficientin their interactions (skills). Optimally,these efforts would occur within acontext of substantial rethinking ofphysician training and not simplythrough the addition of a few disabilityawareness courses.23

Generalist physicians have an importantrole to play in managing the ongoinghealth care of adults with disabilities andimproving the overall health status of thisgroup, but they have received limitedattention in discussions about thedisability-related training needs ofphysicians. The central focus of thisarticle is on improving educationaloutcomes of the generalist physicianswho face unique responsibilities andchallenges in providing supports forPWDs by suggesting a comprehensive listof knowledge, attitudes, and skills toshape training and curricula. Thisapproach is in keeping with the currentemphasis within medical education onthe use of competencies, or knowledge,attitudes, and skills, to guide curriculardevelopment and evaluation strategies.Ultimately, our goal is to influence thebehaviors of generalist physicians, inparticular their posttraining behaviorstoward patients with disabilities, byproviding training to increase theirknowledge, broaden their attitudes, andenhance their skills. Although measurableattainments in knowledge, attitudes, andskills are indeed desired outcomes, theintegration of these into behaviors andpractices that improve the health ofPWDs is the essential and definitiveoutcome.

Dr. Minihan is assistant professor, Department ofPublic Health and Community Medicine, TuftsUniversity School of Medicine, Boston,Massachusetts.

Dr. Robey is director, Matheny Institute forResearch in Developmental Disabilities, MathenyMedical and Educational Center, Peapack, NewJersey, and assistant professor, Department ofPsychiatry, UMDNJNew Jersey Medical School,Newark, New Jersey.

Dr. Long-Bellil is assistant professor, University ofMassachusetts Medical School, Shrewsbury,Massachusetts.

Ms. Graham is rehabilitation engineer, Universityof South Carolina School of Medicine InteragencyOffice of Disability and Health, Columbia, SouthCarolina.

Dr. Hahn is associate professor, Department ofNursing, College of Health and Human Services,Durham, New Hampshire.

Dr. Woodard is associate professor, Department ofFamily Medicine, University of South Florida Collegeof Medicine, Tampa, Florida.

Dr. Eddey is chief medical officer, MathenyMedical and Educational Center, Peapack, NewJersey, and clinical associate professor, Departmentof Pediatrics, UMDNJNew Jersey Medical School,Newark, New Jersey.

The Alliance for Disability in Health CareEducation is a collaborative network of health careeducators promoting the inclusion of disability-related experiences in health care curricula.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

References1 U.S. Department of Health and HumanServices. Healthy People 2010: Understandingand Improving Health. 2nd ed. Washington,DC: U.S. Department of Health and HumanServices; 2000.

2 Gans BM, Mann NR, Becker BE. Delivery ofprimary care to the physically challenged.Arch Phys Med Rehabil. 1993;74:S-15S-19.

3 U.S. Public Health Service. Closing the Gap:A National Blueprint for Improving theHealth of Individuals With MentalRetardation. Report of the Surgeon GeneralsConference on Health Disparities and MentalRetardation. Washington, DC: U.S.Department of Health and Human Services;2002.

4 U.S. Department of Health and HumanServices. The Surgeon Generals Call toAction to Improve the Health and Wellnessof Persons With Disabilities. http://www.surgeongeneral.gov/library/disabilities.Accessed May 24, 2011.

5 Nichols AD, Ward RL, Freedman RI, et al.Left out in the Cold: Health Care Experiencesof Adults With Intellectual andDevelopmental Disabilities in Massachusetts.Waltham, Mass: The ARC; 2008.

6 Barnett S. Communication with deaf andhard-of-hearing people: A guide for medicaleducation. Acad Med. 2002;77:694700.http://journals.lww.com/academicmedicine/Fulltext/2002/07000/Communication_with_Deaf_and_Hard_of_hearing.9.aspx. AccessedMay 25, 2011.

7 Ebert DA, Heckerling PS. Communicationwith deaf patientsKnowledge, beliefs, andpractices of physicians. JAMA. 1995;273:227229.

8 Eddey GE, Robey KL, McConnell JA.Increasing medical students self-perceivedskill and comfort in examining persons withsevere developmental disabilities: The use ofstandardized patients who are nonverbal dueto cerebral palsy. Acad Med. 1998;73(suppl10):S106S108. http://journals.lww.com/academicmedicine/Citation/1998/10000/COGNITION,_CONFIDENCE,_AND_

CLINICAL_SKILLS_.61.aspx. Accessed May25, 2011.

9 Iezzoni LI. What should I say?Communication around disability. AnnIntern Med. 1998;129:661665.

10 Iezzoni LI. Make no assumptions:Communication between persons withdisabilities and clinicians. Assist Technol.2006;18:212219.

11 Iezzoni LI. Going beyond disease to addressdisability. N Engl J Med. 2006;355:976979.

12 Iezzoni LI, McCarthy EP, Davis RB, SiebensH. Mobility impairments and use ofscreening and preventive services. Am JPublic Health. 2000;90:955961.

13 Iezzoni LI, Davis RB, Soukup J, ODay B.Quality dimensions that most concern peoplewith physical and sensory disabilities. ArchIntern Med. 2003;163:20852092.

14 Iezzoni LI, ODay BL, Killeen M, Harker H.Communicating about health care:Observations from persons who are deaf orhard of hearing. Ann Intern Med. 2004;140:356362.

15 Iezzoni LI, Ramanan RA, Drews RE. Teachingmedical students about communicating withpatients who have sensory or physicaldisabilities. Disabil Stud Q. 2005;25(1). http://www.dsq-sds.org/article/view/527/704.Accessed May 24, 2011.

16 Iezzoni LI, Ramanan RA, Lee S. Teachingmedical students about communicating withpatients with major mental illness. J GenIntern Med. 2006;21:11121115.

17 Morrison EH, George V, Mosqueda L.Primary care for adults with physicaldisabilities: Perceptions from consumer andprovider focus groups. Fam Med. 2008;40:645651.

18 ODay BL, Killeen M, Iezzoni LI. Improvinghealth care experiences of persons who areblind or have low vision: Suggestions fromfocus groups. Am J Med Q. 2004;19:193200.

19 Andriacchi R. Primary care for persons withdisabilities. The internal medicineperspective. Am J Phys Med Rehabil. 1997;76(suppl):S17S20.

20 DeJong G, Palsbo SE, Beatty PW. 1. Theorganization and financing of health servicesfor persons with disabilities. Milbank Q.2002;80:261301.

21 Bloom BS. Taxonomy of EducationalObjectives: The Classification of EducationalGoals. New York, NY: Longmans Green;1956.

22 Andrew NR, Siegel BS, Politch L, Coulter D.Teaching medical students about childrenwith disabilities. Pediatric Educ. 1998;4:307316.

23 Basnett I. Health care professionals and theirattitudes toward decisions affecting disabledpeople. In: Albrecht GL, Seelman KO, BuryM,eds. Handbook of Disability Studies. London,UK: Sage Publications; 2001:450467.

24 Kahtan S, Inman C, Haines A, Holland P.Teaching disability and rehabilitation tomedical students. Med Educ. 1994;28:386393.

25 Kitchener BA, Jorm AF. Mental health firstaid training for the public: Evaluation ofeffects on knowledge, attitudes and helpingbehavior. BMC Psychiatry. 2002;2:10.

26 Lennox N, Diggens J. Knowledge, skills andattitudes: Medical schools coverage of an



ideal curriculum on intellectual disability.J Intellect Dev Disabil. 1999;24:341347.

27 Miller TE, Booraem C, Flowers JV, IversenAE. Changes in knowledge, attitudes, andbehavior as a result of a community-basedAIDS prevention program. AIDS Educ Prev.1990;2:1223.

28 Young DR, Haskell WL, Taylor CB, et al.Effect of community health education onphysical activity knowledge, attitudes, andbehavior. The Stanford Five-City Project.Am J Epidemiol. 1996;144:264274.

29 DeJong G. Primary care for persons withdisabilitiesAn overview of the problem.Am J Phys Med Rehabil. 1997;76(suppl):S2S8.

30 Pope A, Tarlov A, eds; Institute of Medicine.Disability in America: Toward a NationalAgenda for Prevention. Washington, DC:National Academy Press; 1991.

31 Burns TJ, Batavia AI, Smith QW, DeJong G.Primary health care needs of persons withphysical disabilities: What are the researchand service priorities? Arch Phys MedRehabil. 1990;71:138143.

32 Janicki MP, Dalton AJ, Henderson CM,Davidson PW. Mortality and morbidityamong older adults with intellectualdisability: Health services considerations.Disabil Rehabil. 1999;21:284294.

33 Bowers B, Esmond S, Lutz B, Jacobson N.Improving primary care for persons withdisabilities: The nature of expertise. DisabilSoc. 2003;18:443455.

34 Conill A. Living with disability: A proposalfor medical education. JAMA. 1998;279:83.

35 Wells TP, Byron MA, McMullen SH, BirchallMA. Disability teaching for medical students:Disabled people contribute to curriculardevelopment. Med Educ. 2002;36:788792.

36 Kirschner KL, Curry RH. Educating healthcare professionals to care for patients withdisabilities. JAMA. 2009;302:13341335.

37 Sallis JF, Owen N. Ecological models of healthbehavior. In: Glanz K, Rimer BK, Lewis FM,eds. Health Behavior and Health EducationTheory, Research and Practice. San Francisco,Calif: Jossey-Bass; 2002:462484.

38 United States Medical LicensingExamination. Test content and practicematerials. http://www.usmle.org/Examinations/step1/step1_content.html.Accessed May 25, 2011.

39 Crotty M, Finucane P, Ahern M. Teachingmedical students about disability andrehabilitation: Methods and studentfeedback. Med Educ. 2000;34:659664.

40 Graham CL, Brown RS, Zhen H, McDermottS. Teaching medical students about disabilityin family medicine. Fam Med. 2009;41:542544.

41 Holder M, Waldman HB, Hood H. Preparinghealth professionals to provide care toindividuals with disabilities. Int J Oral Sci.2009;1:6671.

42 Jacobson EW, GammonW. Usingstandardized-patient instructors to teachstudents about the needs of patients withdisabilities. Acad Med. 1997;72:442. http://journals.lww.com/academicmedicine/Abstract/1997/05000/Using_standardized_patient_instructors_to_teach.77.aspx.Accessed May 25, 2011.

43 Oshima S, Kirschner KL, Heinemann A,Semik P. Assessing the knowledge of futureinternists and gynecologists in caring for awoman with tetraplegia. Arch Phys MedRehabil. 1998;79:12701276.

44 Phillips A, Morrison J, Davis RW. Generalpractitioners educational needs inintellectual disability health. J Intellect DisabilRes. 2004;48:142149.

45 Morrison DM, Baker SA, Gillmore MR.Sexual risk behavior, knowledge, and condomuse among adolescents in juvenile detention.J Youth Adolesc. 1994;23:271288.

46 Campbell FK. Medical education anddisability studies. J Med Humanit. 2009;30:221235.

47 Duckworth SC. The effect of medicaleducation on the attitudes of medicalstudents towards disabled people. Med Educ.1988;22:501505.

48 Paris MJ. Attitudes of medical students andhealth-care professionals toward people withdisabilities. Arch Phys Med Rehabil. 1993;74:818825.

49 Ralston E, Zazove P, Gorenflo DW.Physicians attitudes and beliefs about deafpatients. J Am Board Fam Pract. 1996;93:167173.

50 Robey K, Gwiazda J, Morse J. Nursingstudents self-attributions of skill, comfort,and approach when imagining themselvescaring for persons with physical impairmentsdue to developmental disability. J Dev PhysDisabil. 2001;13:361371.

51 Tervo R, Azuma S, Palmer G, Redinius P.Medical students attitudes toward personswith disability: A comparative study. ArchPhys Med Rehabil. 2002;83:15371542.

52 Thompson T, Emrich K, Moore G. The effectof curriculum on the attitudes of nursingstudents toward disability. Rehabil Nurs.2003;28:2730.

53 Rudman LA, Ashmore RD, Gary ML.Unlearning automatic biases: Themalleability of implicit prejudice andstereotypes. J Pers Soc Psychol. 2001;81:856868.

54 Minihan PM, Bradshaw YS, Long LM, et al.Teaching about disability: Involving patientswith disabilities as medical educators. DisabilStud Q. 2004;24(4). http://www.dsq-sds.org/article/view/883/1058. Accessed May 24,2011.

55 Burgstahler S, Doe T. Disability-relatedsimulations: If, when, and how to use them.Rev Disabil Stud. 2004;1:417.

56 Eddey GE, Robey KL. Considering the cultureof disability in cultural competence education.AcadMed. 2005;80:706712. http://journals.lww.com/academicmedicine/Fulltext/2005/07000/Considering_the_Culture_of_Disability_in_Cultural.19.aspx. AccessedMay 25, 2011.

57 Shakespeare T, Iezzoni LI, Grace NE. The artof medicineDisability and the training ofhealth professionals. Lancet. 2009;374:18151816.

58 Iezzoni LI. When Walking Fails. AddressingMobility Problems of Adults With ChronicConditions. Berkeley, Calif: University ofCalifornia Press; 2003.

59 Stoeckle JD, Ronan L, Ehrlich C, Roberts D.The uses of shadowing the doctorand

patient: On seeing and hearing their work ofcare. J Gen Intern Med. 1993;8:561563.

60 Lee MM, Sonis AL. An instrument to assessdental students attitudes toward thehandicapped. Spec Care Dentist. 1983;3:117123.

61 Dunn ME, Umlauf RL, Mermis BJ. Therehabilitation situations inventory: staffperception of difficult behavioural situationsin rehabilitation. Arch Phys Med Rehabil.1992;73:316319.

62 LamWY, Gunukula SK, McGuigan D, IsaiahN, Symons AB, Akl EA. Validatedinstruments used to measure attitudes ofhealthcare students and professionals towardspatients with physical disability: A systematicreview. J Neuroeng Rehabil. 2010;7:55. http://www.jneuroengrehab.com/content/7/1/55.Accessed May 24, 2011 .

63 Yuker HE, Block JR, Campbell WJ. A Scale toMeasure Attitudes Toward Disabled Persons.Albertson, NY: Human Resources Center;1960. Human Resources Study No. 5.

64 Antonak RF. Development and psychometricanalysis of the Scale of Attitudes TowardDisabled Persons. J Appl Rehabil Couns.1982;13:2229.

65 Siller J, Chipman A, Ferguson LT, Vann DH.Attitudes of non-disabled toward thephysically disabled. In: Siller J, Thomas KR,eds. Essays and Research on Disability.Athens, Ga: Elliott & Fitzpatrick; 1967.

66 Tringo JL. The hierarchy of preferencetoward disability groups. J Spec Educ. 1970;4:295306.

67 Grand SA, Bernier JE, Strohmer DC.Attitudes toward disabled persons as afunction of social context and specificdisability. Rehabil Psychol. 1982;27:165174.

68 Gething L, Wheeler B. The Interaction WithDisabled Persons Scale: A new Australianinstrument to measure attitudes towardspeople with disabilities. Aust J Psychol. 1992;44:7582.

69 Findler L, Vilchinsky N, Werner S. TheMultidimensional Attitudes Scale TowardPersons With Disabilities (MAS):Construction and validation. Rehabil CounsBull. 2007;50:166176.

70 Thomas A, Doyle A, Vaughn D.Implementation of a computer based implicitassociation test as a measure of attitudestoward individuals with disabilities. J Rehabil.2007;73(2):314.

71 Robey KL, Beckley L, Kirschner M. Implicitinfantilizing attitudes about disability. J DevPhys Disabil. 2006;18:441453.

72 Brown RS, Graham CL, Richeson N, Wu J,McDermott S. Evaluation of medical studentperformance on objective structured clinicalexams with standardized patients with andwithout disabilities. Acad Med. 2010;85:17661771. http://journals.lww.com/academicmedicine/Abstract/2010/11000/Evaluation_of_Medical_Student_Performance_on.40.aspx.AccessedMay 25, 2011.

73 Lawless K, Brown S, Carter M. Applyingeducational psychology and instructionaltechnology to health care issues: CombatingLyme disease. Int J Instr Media. 1997;24:287297.

74 Saketkoo L, Anderson D, Rice J, Rogan A,Lazarus CJ. Effects of a disability awarenessand skills training workshop on seniormedical students as assessed with self ratings



and performance on a standardized patientcase. Teach Learn Med. 2004;16:345354.

References Cited in Lists Only75 Reis JP, Breslin M, Iezzoni LI, Kirschner KL.

It Takes More Than Ramps to Solve the Crisisof Healthcare for Persons With Disabilities.Chicago, Ill: Rehabilitation Institute ofChicago; 2004.

76 Marshall J, Haines A. Survey of the teachingof disability and rehabilitation to medical

undergraduates in the UK. Med Educ. 1990;24:528530.

77 Hoeman SP, Duchene PM, Vierling L.Ethical and legal issues in rehabilitationnursing. In: Hoeman SP, ed. RehabilitationNursing: Prevention, Intervention andOutcomes. St. Louis, Mo: Mosby Elsevier;2008:3044.

78 Jain S. Care of patients with disabilities: Animportant and often ignored aspect of

family medicine teaching. Fam Med. 2006;38:1315.

79 Gans BM. Primary care for persons withdisabilities: Establishing a vision for thefuture. Am J Phys Med Rehabil. 1997;76(3 suppl):1.

80 Field MJ, Jette AM, eds; Institute of Medicine.The Future of Disability in America.Washington, DC: National Academies Press;2007.



desired educational outcomes of disability- related training for the generalist physician:...

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