1. University at Buffalo Department of Family Medicine Andrew Symons, MD, MS Denise McGuigan, MSEd Reva Fish, PhD

2. Prevalence Estimated that at least one in eight Americans (34 million people) is living with a disability 1

3. Disparity Healthy People 2010 identifies people with disabilities as a vulnerable, at-risk population, subject to health care disparities: increased rates of secondary conditions such as heart disease lack of access to health care services lower rate of screening and preventive care services

4. Barriers to Care Physical (inaccessibility of facilities and equipment to people with disabilities) 2 Deficiencies in knowledge, attitudes and skills of health care providers 2  Negative attitudes and behaviors of health care providers are the most formidable barriers to accessing health care services 3  Negative attitudes can result in withholding treatment, giving inferior treatment and neglecting general and preventive care 4

5. Rarely Addressed in Curricula Despite evidence that early and frequent encounters with people with disabilities improves students’ knowledge, attitudes and skills regarding care for people with disabilities… rarely addressed directly in medical school curricula 5

6. Needs Assessment International (WHO) National (IOM, Healthy People 2101, Surgeon General) Local (course directors, students, residents, agencies, patients/families)

7. Instituting a Curriculum on Disabilities Integrated 4-year medical school curriculum to address caring for patients with disabilities

8. Students Demonstrate Skill In: effective communication with people who have disabilities and their families examination of patients who have a disability appropriate referral to community organizations and specialists resourcing information from caregivers and families

9. Modalities Include didactic teaching didactic teaching encounters with patients and standardized patients with disabilities encounters with patients and standardized patients with disabilities training of standardized patients with disabilities training of standardized patients with disabilities meetings with families of patients with disabilities meetings with families of patients with disabilities presentations by patient- advocates presentations by patient- advocates visits to community organizations serving people with disabilities visits to community organizations serving people with disabilities research experience research experience precepted clinical exposure precepted clinical exposure

10. Module Examples CPM I – Lecture on Disability and Society/meetings CPM II – Standardized patient activity Family Med Clerkship – Precepted clinical experience and social/legal workshop Internal Med Clerkship – Lecture on common medical concerns Fourth Year – Elective on Primary Care for Patients with Disabilities

11. Evaluation in General Modes include: OSCE evaluations reflective diaries formative feedback from preceptors and patients baseline and follow-up attitudinal assessment (pre/post-test)

13. Attitudinal Assessment Tool Developed a pre/post-test instrument to measure medical student attitudes and comfort level toward people with disabilities Administered to students prior to exposure to the curriculum and at the end of the curriculum, as well as control groups

14. Development Conducted systematic literature review Developed initial instrument with content derived from:  review of previously published and cited instruments  input from colleagues and experts who work with people with disabilities  medical educators  patients and families

15. Development Construct validity was established through a cycle of instrument item reviews by experts in the field of treatment of persons with disabilities

16. Components of the Instrument Demographics (age/gender) Two questions about professional and personal experience interacting with people with disabilities 18 Likert scale items (1-4), strongly agree to strongly disagree measuring general comfort level with people with disabilities, i.e.,  I would be comfortable being around a person who uses a wheelchair.  If I introduced a person with disabilities to my friends, I think they would feel uneasy.

17. You enter the exam room. A middle-aged man and women are there. He tells you he is experiencing chronic abdominal pain. Strongly Disagree Disagree Agree Strongly Agree 1.I have had experiences similar to scenario A. 1234 2. In scenario A, I would be comfortable determining the role of the man vs. the woman in providing the history of the complaint. 1234 3. In scenario A, I would be comfortable performing a physical exam on the patient. 1234 4. In scenario A, I would be comfortable establishing a differential diagnosis for the abdominal pain. 1234 Scenario A

18. Scenario B You enter the exam room. A middle-aged man is seated in a wheelchair. Standing behind him is a woman of about the same age. The patient in the wheelchair appears to have spasticity in all 4 limbs. He greets you by saying “hello.” His speech is somewhat garbled, though intelligible. The woman tells you that the patient is here because he is experiencing chronic abdominal pain.

19. Open-Ended Question Consider scenarios A and B. Are there elements in either scenario which would make you uncomfortable in the clinical encounter? If so, please describe briefly.

20. Methods Administered to (n=342): 129 first-year medical students participating in CPM 1 79 second-year medical students participating in CPM 2 17 third-year medical students participating the Family Medicine Clerkship 117 first-year medical students at other medical school in New York State

21. Results Psychometric analysis included internal consistency reliability analysis and factor analysis using principle components method of extraction Internal consistency reliability  Cronbach alpha of.857  No notable increase possible by deletion of any items  Very good internal consistency reliability for this instrument with this sample

22. Results Factor analysis using principle components method of extraction Five components or subscales were found: 1.Comfort interacting with people with disabilities 2.Working with patients with disabilities 3.Negative impressions of self-concepts of people with disabilities 4.Positive impressions of self-concepts of people with disabilities 5.Conditional comfort with people with disabilities

23. Results Two items were removed from the instrument because they did not load on a single component and item loading was <.4 Review of the these items revealed that complexity of wording may have confused some participants

24. Future Refine instrument through future data collection and psychometric analysis Improve the wording of some items Administer at the end of the curriculum Disseminate final instrument for use in other medical schools

25. References 1. Fast stats A to Z: Disabilities or Limitations [http://www.cdc.gov/nchs/fastats/disable.htm]http://www.cdc.gov/nchs/fastats/disable.htm 2. Field MJ, Jette AM, Institute of Medicine (U.S.). Committee on Disability in America: a New Look. The future of disability in America. Washington, DC: National Academies Press; 2007. 3. Drainoni M, Lee-Hood E, Tobias C, Bachman S, Andrew J, Maisels L. Cross-disability experiences of barriers to health-care access. Journal of Disability Policy Studies. 2006;17:101-115. 4. Jackson KB: Knowledge and attitudes toward persons with physical disabilities of healthcare trainees. Master Thesis. Roosevelt University, Clinical Psychology Department; 2007. 5. Crotty M, Finucane P, Ahern M. Teaching medical students about disability and rehabilitation: methods and student feedback. Medical Education. Aug 2000;34(8):659-664.