Curriculum on Developmental Disabilities in Family Medicine Residency

Bernadette Riley, DO, FACOFP, FILM | briley@nyit.edu

No relevant financial affiliations

INTRODUCTION

According to the Center for Disease Control there are approximately one in six children in the United States living with developmental disabilities (DD).1 Since the American Disability Act was passed in 1990, new laws have been put into place to expand opportunities for Americans living with all types of disabilities.2 "Developmental disabilities are a group of conditions due to an impairment in physical, learning, language or behavior areas."3 DD occurs before the age of 22, and last throughout one's life.4 In the United States, the most common form of DD is an intellectual disability, followed by cerebral palsy and autism spectrum Disorders (ASD).4 Most family medicine physicians in the US will encounter a patient with DD. Family physicians must realize that they need training in treating patients with DD. This training includes addressing the health disparities related to patients who have a DD.5 Patients with DD have a shorter lifespan than the average population.5 The Department of Health and Human Services launched “Healthy People 2020” to “improve the quality of life among individuals with disabilities of all ages.”6 Due to this increase in awareness, the osteopathic family physician needs to be properly trained in treating and identifying patients with developmental disability. This training should continue to occur during the Family Medicine residency. With the Single GME Accreditation System culminating by July 2020, now is the time to ensure family medicine trainees are taught in recognizing and caring for patients with DD.

WHY THE OSTEOPATHIC FAMILY MEDICINE COMMUNITY NEEDS TRAINING ON PATIENTS WITH DD

Since some developmental disabilities are increasing in frequency among the US population7, the osteopathic family physician needs to be educated in not only treating, but also identifying this population. In 2017, at the American Medical Associations' House of Delegates (AMA HOD), a resolution was passed that the "AMA recognize the importance of managing the health of children and adults with developmental disabilities as a part of overall patient care for the entire community."8 The resolution further states the "AMA encourage graduate medical education programs to develop and implement a curriculum on providing appropriate and comprehensive health care to people with DD."8 In July 2018 the AOA House of Delegates (AOA HOD) approved resolution H-211 that states “that the AOA encourage osteopathic medical schools to develop and implement curricula on the care of people with developmental disabilities.”9 With the passage of resolutions by the AMA in 2017, the AOA in 2018, and the Single GME Accreditations System in place, it is imperative that the osteopathic community recognize the importance of training our residents on patients with DD. Osteopathic Family Medicine residents should be trained to recognize and properly treat patients with DD during their residency.

NEED FOR TRAINING NOW

In a recent survey, the majority of medical and dental students surveyed "expressed inadequate competency in the care of [patients with DD]."10 Drs. Holder, Waldman, and Hood showed in this study that medical and dental residency program directors "indicated a need for additional training for their residents."10 This further shows the need for training in family medicine residency programs. The reason why this curriculum is imperative is that "persons with disabilities [are] an unrecognized health disparity population."11 Often times the patient with a developmental disability interacts first with a family medicine physician before any other specialty. It is imperative that osteopathic family medicine residents are trained in properly identifying patients with DD.

BARRIERS TO CARE FOR PATIENTS WITH DD

Children and adults with DD have more barriers to health care than others.12 One barrier patients with DD have is a financial one, as patients with DD often have economic barriers, and may depend on governmental institutions or other sources of financial help for medical and/or living expenses.10 There is also a stigma and prejudice associated with DD, and the health care provider can also have a stigma about patients with DD.10 For clinicians who have not been trained in DD, many feel ill-prepared to deal with the patient with DD.10 Through exposure to individuals with DD, the clinicians can see whether they show an "unconscious bias" to patients with DD.10 This bias can be addressed, recognized and possibly remediated during family medicine training so that when the resident graduates they have a better understanding of caring for patients with DD. Many patients with DD have physical barriers to accessing care. These include walking devices, such as wheelchairs or auditory aides that may make it challenging for a patient with DD to get to the doctor.10 Patients with DD can sometimes present communication challenges with their healthcare providers. Since "effective two-way communication is foundational to person- centered care" this can present an issue in the developmentally disabled population.12 The family medicine resident can identify barriers to care that may be in place and learn to use a variety of methods to care for this population.

HEALTHCARE PROFESSIONALS ALREADY UTILIZING A CURRICULUM ON PATIENTS WITH DD

Dental schools across the USA have realized the need of having a curriculum in patients with DD for over a decade. In 2004, The Commission on Dental Accreditation adopted standards to “prepare dental professionals for the care of persons with DD.”13 There are many secondary dental comorbidities seen in patients who have DD. The dental community has revised many standards, and education has been updated as the environment surrounding DD has changed. Dental schools have ensured that all US dental graduates are trained in dealing with patients who have DD.13 Substantial research has been done in the dental community on patients with DD. The time is now for the osteopathic family physician to also ensure proper training in patients with DD.

DIFFERENT STRATEGIES TO MEET DD CURRICULUM REQUIREMENTS

There are many ways that the dental community has tried to educate their dentists on patients with DD. One avenue dental professionals have used to educate learners is by incorporating simulation to teach the provider about DD.14 This type of model can be used with a "flipped classroom" setting, where students are exposed to video or modules before their in-person face to face, or simulation.15 This is beneficial as the learner can go at their own learning pace, and can prepare properly for their face to face teaching session with faculty. Research has shown that the "flipped classroom" method has been used to teach medical students regarding new developmental disability law and practice with good results.15 This type of learning is a good way to engage family medicine residents in their training programs without using a lot of time and financial resources. The osteopathic family medicine community can start with a module using the flipped classroom as a way to ensure training in the field of developmental disability. Research from the dental community can help facilitate the family medicine training curriculum for residency programs.

Exposing family medicine residents to simulated scenarios involving children and adults with DD can help the trainees become comfortable taking care of the patient with DD. A study by Drs. Kleinert HL, Sanders C, Mink J, Nash D, Johnson J, Boyd S, Challman S showed dental students who were exposed to a “virtual patient module” of a developmentally disabled child felt satisfied and prepared for a real patient encounter.14 “Educational encounters including personal encounters with patients, modeling by mentors, and reflective activities can foster qualities such as compassion and empathy.”12 Both of these qualities are imperative to the family physician, and for participating in the care of a child or adult with DD.

Some curriculum regarding DD incorporate simulation scenarios where “patients with disabilities [serve] as medical educators.”16 At Tufts University School of Medicine, “people with disabilities, in the role of “standardized” patients, portray patients with a common primary care complaint in simulated medical interviews.”16 This simulated learning environment can be especially promising for the osteopathic family medicine resident, where the resident can evaluate their encounter with a developmentally disabled patient.

Another avenue where family medicine residents can be taught about patients with DD is during a rotation. Clinical rotations and clinical clerkships can expose the trainee and student to patients with DD.17 Graham et al. showed how exposing third-year medical students on their family medicine rotations to a 90-minute curriculum on patients with "mobility and cognitive impairments" helped the students' "knowledge and attitude" on the topic.18

PATIENTS WITH DD AND LONG-TERM ISSUES

There are long-term issues that need to be addressed for a patient with DD. Formal standardized training should be incorporated into family medicine residency to address these long-term issues. A Canadian study by Dr. Sullivan et al. showed that treatment of a developmentally disabled patient involves "caregivers, adapting procedures when appropriate and seeking input from a range of health professionals.”19 This type of comprehensive care is seen every day in the continuity of care that family physicians encounter.

OSTEOPATHIC MEDICAL COMMUNITY AND DIAGNOSIS OF DD

By incorporating curricula on DD in family medicine residency, the physician can identify a patient with a DD. This is especially important for identifying patients who would benefit from early intervention.20 Since “one-half of American children with DD [are] not identified by the time they enter kindergarten” these patients lose valuable opportunities for early intervention strategies.20 Osteopathic family physicians who conduct well visits and testing on specific developmental traits can identify a patient who has a developmental disability. Identifying these patients in early childhood would help the patient and caregiver find appropriate care and access appropriate services. Family medicine residents can also ask caregivers and parents to help access the need for early intervention.21 By training our osteopathic Family Medicine residents in early intervention, this can potentially lead to greater recognition of patients with DD, and potential help and aide earlier in their diagnosis.

CONCLUSION

With the passage of the AMA and AOA HOD resolutions encouraging implementation of a curriculum on patients with DD8, 9 and the Single GME Accreditation System finalizing in 2020, now is the time to standardize the curriculum for family medicine residents on DD. The osteopathic family medicine community should recognize and encourage a model for identifying and treating patients with DD. By standardizing this curriculum and ensuring that Family Medicine resident get training in this population we can ensure appropriate care for the growing number of patients with DD. This curriculum can also help identify the disparity that exists in healthcare for patients with DD and can help address the need to break those barriers.

REFERENCES:

1. Center for Disease Control and Prevention (CDC), Determining How Many People Have Developmental Disabilities- Tracking. https://www.cdc. gov/ncbddd/developmentaldisabilities/about.html Accessed July 9, 2018.

2. CDC, Key Findings: Prevalence of Disability and Disability Type Among Adults, United States- 2013. https://www.cdc.gov/ncbddd/

   disabilityandhealth/features/key-findings-community-prevalence.html Accessed July 9, 2018.

3. CDC, Facts about Developmental Disabilities. https://www.cdc.gov/ ncbddd/developmentaldisabilities/facts.html Accessed July 9, 2018.

4. May Institute- DD Q & A www.mayinstitute.org. https://www. mayinstitute.org/pdfs/NEW%20pdfs/DD%20Q&A_rev4-10.pdf Accessed July 9, 2018.

5. Lauer E, McCallion P. Mortality of People with Intellectual and Developmental Disabilities from Select US State Disability Service Systems and Medical Claims Data. JARID 2015;28 (5): 394-405. doi. org/10.1111/jar.12191

6. Healthy People 2020. Disability and Health. https://www.healthypeople. gov/2020/topics-objectives/topic/disability-and-health. Assessed July 9, 2018.

7. Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011 Jun;127(6):1034-42. doi: 10.1542/peds.2010-2989. Epub 2011 May 23.

8. American Medical Association House of Delegates Resolution: 315 A-17, 2017. https://www.ama-assn.org/sites/default/files/media-browser/public/bot/a17-bot-reports.pdf Accessed July 9, 2018.

9. American Osteopathic Association 2018 House of Delegates Resolutions: Committee on Educational Affairs H-211. https://osteopathic.org/wp- content/uploads/A2018-200-Series-WITHACTION.pdf Accessed August 21, 2018.

10. Holder M, Waldman B, Hood H. Preparing Health Professionals of Caring for Disabled Individuals. International Journal of Oral Science. 2009; 1(2): 66-71.

11. Krahn GL, Walker DK, Correa-De-Araujo, R. Persons With Disability as an Unrecognized Health Disparity Population. Am J Public Health. 2015 Apr;105 Suppl 2: S198-206. doi: 10.2105/AJPH.2014.302182. Epub 2015 Feb 17.

12. .Boyd, K. The Curriculum of Caring: Fostering Compassionate, Person- Centered Health Care. AMA Journal of Ethics. 2016 Apr; 18 (4): 384-392. doi: 10.1001/journalofethics.2016.18.4.medu1-1604.

13. Waldman HB, Fenton SJ, Perlman SP, Cinotti DA. Preparing Dental Graduates to Provide Care to Individuals with Special Needs. J Dent Educ. 2005 Feb;69(2):249-54.

14. Kleinert HL, Sanders C, Mink J, Nash D, Johnson J, Boyd S, Challman S. Improving student dentist competencies and perception of difficulty in delivering care to children with developmental disabilities using a virtual patient module. J Dent Educ. 2007 Feb;71(2):279-86.

15. Sheppard ME, Vitalone-Raccaro N, Kaari JM, Ajumobi TT. Using a flipped classroom and the perspective of families to teach medical students about children with disabilities and special education. Disabil Health J. 2017 Oct;10(4):552-558. doi: 10.1016/j.dhjo.2017.03.012. Epub 2017 Mar 27. 

16. Minihan PM, Bradshaw YS, Long LM, et al. Teaching About Disability: Involving Patients with Disabilities as Medical Educators. Disability Studies Quarterly Fall 2004; 24 (4). DOI: http://dx.doi.org/10.18061/dsq. v24i4.883

17. Havercamp SM, Navas Macho P. (2016) What Undergraduate and Graduate Students Should Know About Disability. In: Rubin I.L., Merrick J., Greydanus D.E., Patel D.R. (eds) Health Care for People with Intellectual and Developmental Disabilities across the Lifespan. Springer, Cham Springer Link 2125-2131. doi.org/10.1007/978-3-319-18096-0_160

18. Graham CL, Brown, RS, Zhen H, McDermott S. Teaching Medical Students About Disability in Family Medicine. Fam Med. 2009;41(8):542- 4 41, 8, 542-544.

19. Sullivan WF, Berg JM, Bradley E et al. Primary care of adults with developmental disabilities. Can Fam Physician. 2011 May; 57(5): 541–553.

20. Mackrides P, Ryherd S. Screening for Developmental Delay. Am Fam Physician. 2011 Sep 1;84(5):544-9.

21. Vitrikas K, Savard D, Bucaj M. Developmental Delay: When and How to Screen. Am Fam Physician. 2017 Jul 1;96(1):36-43.