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An Educational Intervention to Teach Medical Students About Examining Disabled Patients
To The Editor: With an aging population and the trend toward mainstreaming care for persons with disabilities, physicians in all specialties are encountering greater numbers of patients with physical disabilities.1-2Nonetheless, persons with disabilities often have difficulty finding physicians who are knowledgeable about their health care needs.2-3 Lack of familiarity with proper positioning techniques can lead to an inadequate physical examination, as well as uncomfortable and unsafe experiences for patients. Furthermore, physicians who lack these skills often feel overwhelmed in their interactions with disabled patients.4-5
However, positioning skills are relatively easy to learn and are often taught to nonphysician staff such as nurses and therapists. We undertook a study to see if providing structured training in techniques of movement and positioning would improve the ability of medical students to perform these maneuvers.
Methods
Between March 1999 and February 2000, 129 medical students participated in the study during their required third-year general internal medicine clerkship at the Medical College of Wisconsin (Milwaukee). Of these, 64 students were randomly assigned to an intervention of a 90-minute training workshop on positioning and movement of disabled persons in bed or a wheelchair. The other 65 had the same general clinical experiences as the intervention group, but were not exposed to the workshop.
Students were evaluated within 10 to 20 days of the intervention with an objective structured clinical examination (OSCE) involving a simulated patient.6 The OSCE involved turning a simulated patient with right-sided hemiplegia to the left-side lying position and then returning the simulated patient to a supine position after examining the back. A faculty observer evaluated student performance with a 7-item checklist in a yes-or-no format. At the end of the session students were asked to rate the usefulness of the training session.
Results
The intervention group performed significantly better than the control group ( 2 = 13.5, P<.001) for all 7 items evaluated (Table 1). No single item was performed correctly by a majority of students in the control group. There was no difference (P = .62) in final clerkship scores between the control and intervention groups as measured by the t test, thus indicating similar levels of overall clinical competence. Students in the intervention group gave the workshop an average rating of 8.4 of 10.
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Table. Student Performance on Items Evaluated in the Positioning OSCE*
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Comment
In an era of increasing use of medical technology, such basic skills as patient positioning and movement may seem unimportant. We believe, however, that the opposite is true. The physical examination is still widely thought to comprise the most frequently used set of diagnostic and screening tests in medical practice, and a high level of skills in physical diagnosis is essential to reduce the cost of medical care without decreasing its quality. However, there is evidence that in encounters with disabled patients, physicians tend to order unnecessary and expensive tests.1, 3 Training in clinical skills for working with disabled patients would likely increase physician comfort and confidence in performing optimal clinical examinations. Medical school curricula should include structured teaching in positioning and examining disabled patients.
AUTHOR INFORMATION
Funding/Support: This study was supported by an award from the Learning Resources Fund of the Medical College of Wisconsin, Milwaukee.
Acknowledgment: We thank Leah Cartwright, PT, and Rosemary Ehrgott, PT, for assisting with the training workshop, Susan M. Fehring for providing administrative support, and Prakash W. Laud, PhD, and Daniel Eastwood, MA, for their statistical support.
Sunil Sabharwal, MD;
James L. Sebastian, MD
Medical College of Wisconsin
Milwaukee
Michelle Lanouette, PT
Clement J. Zablocki Veterans Affairs Medical Center
Milwaukee, Wis
1. Batavia A, DeJong G, Halstead L. Primary medical services for people with disabilities. Am Rehabil. 1989;14:9-27.
2. Pope MA, ed, Tarlov AR, ed. Disability in America: Towards a National Agenda for Prevention. Washington, DC: National Academy Press; 1991.
3. DeJong G, Batavia A, Griss R. America's neglected health minority: working age people with disabilities. Milbank Q. 1989;67(suppl 2):311-351.
4. Andriacchi R. Primary care for people with disability: the internal medicine perspective. Am J Phys Med Rehabil. 1997;76(suppl 3):S17-S20.
5. Werner P. Primary care for people with disability: the family practice perspective. Am J Phys Med Rehabil. 1997;76(suppl 3):S21-S24.
6. Vu NV, Barrows HS. Use of standardized patients in clinical assessments: recent developments and measurement findings. Educ Res. 1994;23:23-30.
Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Phil B. Fontanarosa, MD, Executive Deputy Editor.
JAMA. 2000;284:1080-1081.
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