Nothing About Us Without Us: Improving Representation of Disability in Medical School Curriculum Through Explicit Inclusion.

ABSTRACT: Medical school curricula across the United States fail to adequately prepare students to provide high-quality care to and advocate for patients with disabilities. To address this shortcoming at one large, urban medical school, the Curriculum Committee at Sidney Kimmel Medical College (SKMC) formed a taskforce of students and faculty to evaluate the degree and quality of disability representation in its undergraduate medical education (UME) curriculum. Taskforce members solicited input from five community members in various fields of disability advocacy to craft recommendations that reflected this community's vision for disability education in UME. Community partners suggested areas of focus including clinical skills, accessibility of healthcare facilities, awareness of intersectionality with other identities, acknowledgment of bias, and respect for the patient's autonomy via their "right to risk." The taskforce report to the Curriculum Committee included 9 recommendations for curricular revision based on community partner suggestions, 6 of which were accepted and are being implemented into the curricular content for the class of 2026 and beyond. This novel approach to implementing curricular change could encourage other medical schools to evaluate their own curricula through the lens of disability and prompt curricular revision with the input of community partners with disabilities, students, and, faculty.

Student-Led Workshop on Disability Advocacy.

ABSTRACT: Medical students can be powerful advocates for and in partnership with the disability community, yet opportunities for targeted advocacy training are sparse. In February 2023, a medical student-led workshop on disability advocacy for trainees took place at the Association of Academic Physiatrists' Annual Conference. The aims of this session were for trainees to (1) identify existing gaps in disability education at their institution and in policy around disability-related issues; (2) improve perceived ability to engage in disability-related education and policy-based advocacy; and (3) apply an intersectional lens to identify opportunities for intersectionality in disability advocacy. Pre- and post-session responses were anonymously submitted via Qualtrics. Of 31 pre-survey respondents, 18 responded to the post-survey, and 12 were identified as having matching unique identifiers. After the workshop, participants overall were more likely to report being very/somewhat confident about their ability to identify gaps in disability education at their institution (75.0% vs 100.0%, p = 0.011), policy around disability-related issues (41.7% vs 100.0%, p < 0.006), and opportunities for intersectionality in disability advocacy (33.3% vs 91.7%, p < 0.015). Participants were more likely to report being very/somewhat confident in engaging in education-based advocacy (58.3% vs 100.0%, p = 0.006), policy-based advocacy (16.7% vs 91.7%, p < 0.002) and intersectional disability advocacy (41.7% vs 91.7%, p < 0.006). All attendees strongly/somewhat agreed with the statements "I hope that this session will continue in future years" and "I think that other trainees would benefit from a similar course." This session was shown to effectively meet the intended goals of the program.

Twelve tips for including disability education in undergraduate medical education.

Disability is a large and growing minority population worldwide. People with disabilities continue to experience health and healthcare disparities. Despite multiple calls to action to provide disability education within undergraduate medical education as a strategy to mitigate ongoing inequities, robust disability education is not routinely provided across medical schools. This article provides twelve tips that any medical school faculty can utilize to integrate meaningful disability education within existing core medical education.

Equitable Care for Patients With Disabilities: Considerations for the Gynecologic Health Care Professional.

All patients deserve high-quality health care. Patients with disabilities have historically experienced discrimination in health care and subsequently detrimental health outcomes. Health care professionals often lack confidence and preparedness in treating patients with disabilities effectively. Barriers such as communication difficulties, biased assumptions, and inadequate equipment hinder comprehensive care. These barriers to care lead to health inequalities and a diminished overall quality of life for individuals with disabilities. Existing clinical guidelines for care of this underserved population are lacking. This article establishes a comprehensive educational framework and accessible reference tools for gynecologic health care professionals to enhance their ability to offer inclusive and effective care to patients with disabilities. Insights in this article stem from expert consensus among clinicians experienced in this field and ongoing dialog with community-based disability care partners. We present actionable steps to cultivate an open, adaptable, and patient-centric method to actively engage patients and to provide suitable accommodations when needed.

Navigating Uncertainty in Clinical Practice: A Workshop to Prepare Medical Students to Problem-Solve During Complex Clinical Challenges.

Introduction: Uncertainty is an inherent part of medicine. Prior work has trained medical students to better communicate diagnostic uncertainty; however, this work touches on only one aspect of the uncertainty students will face in practice. We developed a session to provide them with a taxonomy for categorizing the various types of uncertainty, as well as a framework to apply when navigating uncertainty during clinical challenges. These tools can help students make sense of uncertainty and determine actions in a complex health system. Methods: We designed a virtual workshop for third-year medical students at the end of their core clerkships. It included a didactic session followed by a small-group immersive unfolding case experience with several challenge points during which we tasked students with applying the framework, classifying the uncertainty domain, and discussing how they would problem-solve each scenario. Results: We conducted the workshop with 128 third-year medical students. We collected data through an anonymous postsession survey (86% response rate; 110 of 128 students). Most found the workshop useful (64%; 54 of 85), and a large number found the framework helpful in appraising uncertainty (47%; 42 of 89). A majority felt their perspectives on uncertainty changed after the workshop (66%; 73 of 110). Students integrated prior health systems science knowledge in their strategies to problem-solve each challenge. Discussion: This session provides a novel application of a sense-making framework and taxonomy for medical students to classify uncertainty. It offers a simple, low-cost, interactive, virtual activity that can be implemented at other institutions.

Disability-Specific Education in US Internal Medicine Primary Care Residency Programs: A Survey of Program Directors.

Phenomenon: The dearth of disability-specific education in United States medical schools and residency programs has perpetuated health care inequities experienced by people with disabilities. In this study, we surveyed internal medicine primary care residency program directors about the disability-specific education they offer their learners, their attitudes toward physicians' preparedness to care for people with disabilities, and their perceived challenges to offering more robust disability-specific education. Approach: We developed an on-line survey and forwarded it in 3 weekly emails during October of 2022 to 104 primary care residency program directors. We collected basic information about the residency programs and queried whether they were providing disability-specific education to their residents, which topics were being covered, and perceived barriers to offering additional disability-focused curricula. Data analyses included descriptive statistics, chi-squared, and independent samples t-tests. Findings: Forty-seven program directors responded (response rate 45.2%). The largest plurality of programs was in the Northeast, their average number of primary care residents was 15.6, most (67.4%) hosted primary care clinics in hospitals or academic centers, and 55.6% had affiliated divisions or departments of rehabilitation medicine. The majority of respondents felt that both internists and their own residents (88.3% and 77.8%, respectively) are inadequately educated in the care of people with disabilities, yet only 13 (28.9%) offered disability-focused curricula, and they tended to be narrow in scope. Only 8 of those 13 respondents (61.5%) reported that their disability curricula were required, rather than optional. Participants listed a number of barriers to implementing disability-focused education including a lack of advocacy for such work (65.2%), lack of time in the curriculum (63.0%), lack of expectation by educational governing boards that physicians understand disability-specific care considerations (60.9%), and lack of affiliated expertise in the care of people with disabilities (52.2%). Insights: While the program directors training future primary care physicians largely understand that physicians are inadequately prepared to offer equitable health care to individuals with disabilities, few of them are offering disability-specific education to their residents and most see significant barriers to doing so.

Exposing the disability-related hidden curriculum in case-based learning: A qualitative study.

BACKGROUND: People with disabilities face significant health disparities. Studies show that healthcare professionals harbor negative attitudes towards disability, compromising the quality of care. These attitudes, in unwritten, unofficial, and even unintended ways can be passed from providers to learners in the medical education setting. OBJECTIVE: Using a Critical Disability Studies (CDS) paradigm, the authors uncovered the disability-related hidden curriculum within Case-Based Learning (CBL) and proposed guidelines for promoting a disability-conscious medical education that resists ableism. METHODS: The study team conducted a qualitative analysis of all CBL cases from the pre-clerkship curriculum (n = 53) at Sidney Kimmel Medical College. The authors employed a directed content analysis approach to develop a codebook based on case examination, literature review, and CDS concepts. Two researchers coded all cases and assessed intercoder reliability. The results informed the development of an explanatory model. RESULTS: Only four of 53 cases overtly mentioned disability, none of which defined disability according to CDS. Coding did not identify content challenging stereotypical views of disability. Additionally, two cases included content fueling negative attitudes of disability. CONCLUSION: By inadequately addressing disability from a CDS perspective, harmful assumptions of disability may go unchallenged, driving a hidden curriculum within CBL. This phenomenon leaves medical students ill-prepared to care for people with disabilities and creates physicians ill-equipped to teach the next generation. Since many health professions utilize CBL to educate students, these cases provide an untapped opportunity to resist ableism and better prepare students to address the negative attitudes driving health disparities experienced by people with disabilities.

Practical tips for moving your patient panel online.

Patient panels are an inspiring, highly rated educational tool to complement course goals and objectives for students in medical education programs. The COVID-19 pandemic brought challenges on the ability to successfully host in-person patient panels. These challenges resulted in the need to pivot in-person patient panels to online platforms, while still ensuring the quality and intimacy of patient narratives. In this 12 tips article, we share lessons learned in transitioning patient panels in our health systems science curriculum to an online experience for students enrolled in a pre-clinical medical education program.

Intolerance of uncertainty and attitudes towards persons living with disabilities in medical students: Is there a correlation?

Introduction: Patients living with a disability experience an illness trajectory that may be uncertain. While navigating clinical uncertainty has been well-researched, health professionals' intolerance of uncertainty for patients living with disabilities has yet to be explored. We examined the relationship between medical students' intolerance of uncertainty with their attitudes towards people living with disabilities to better inform curricular efforts. Methods: We employed a survey-based design consisting of the Intolerance of Uncertainty Scale (IUS) and Disability Attitudes in Healthcare (DAHC) Scale to medical students upon completion of core clerkships (end of third-year of training). Data were de-identified. Mean DAHC and IUS scores were compared with published values via t-test. Linear regression was used to examine IUS/DAHC scores for anonymized students. Pearson correlation coefficient was calculated to assess correlation between IUS and DAHC scores. Results: Response rate was 97% (268/275 students). Mean IUS score did not differ from previously cited medical student scores, but mean DAHC score was significantly higher than previously cited scores. We observed a statistically-significant relationship between IUS and DAHC scores. Students with greater intolerance of uncertainty had lower scores for disability attitudes [F(1,243) = 8.05, value of p < 0.01], with an R 2-value of 0.032, suggesting that 3% of DAHC score variance can be explained by IUS score changes. Conclusion: We identified a weak negative correlation between IUS and DAHC scores in medical students. Further research is needed to clarify findings and identify best practices that equip trainees with skills to care for patients with uncertain illness trajectories and patients living with disabilities.

The implementation of a required book club for medical students and faculty.

More medical schools are incorporating wellness activities and the medical humanities into their curriculum. Finding implementable programming that is feasible and enjoyable is challenging. Both student participants and faculty who might facilitate programs are busy with clinical and educational responsibilities. Book club discussions in general are an activity that bring people together and expose groups to literature. In medical education, informal books clubs have been shown to increase camaraderie and expose participants to topics in medicine that they may not have encountered without the structure of the group assignment. At one large private urban medical school, all fourth year medical students were required to participate in a one-time hour-long book discussion with a faculty member one week before Match Day 2021. This paper describes the implementation of that program and discusses survey results from 179 students who broadly indicated that the books were enjoyable, the discussions were enriching, and that the program should continue for future classes of medical students.

Going Virtual: A Virtual Summer Physical Medicine and Rehabilitation Externship Experience for Medical Students.

ABSTRACT: Opportunities for early medical student exposure to the field of physical medicine and rehabilitation (PM&R) are desirable for promoting the field as a career choice and are useful for introducing students to the care of people with disabilities. The COVID-19 pandemic disrupted medical education and caused the cancellation of many in-person clinical programs, including the Medical Student Summer Clinical Externship in PM&R supported by the Association of Academic Physiatrists. This article describes the process by which an in-person summer clinical externship program was effectively converted into a Virtual PM&R Experience using a combination of independent assignments and small-group sessions. A total of 87 medical students completed the Virtual PM&R Experience over two summers. The participants of the program met the program learning objectives, including enhancing their understanding of physiatry as a career and recognizing the medical and social issues that affect persons with disability.

Impact of Exercise Prescription Education on Medical Student Confidence and Knowledge in Generating Exercise Recommendations.

Despite physical activity being a key component of maintaining health and preventing disease progression, medical schools are not providing sufficient education on physical activity to medical students. As a result, medical students and new residents express a lack of confidence and knowledge when engaging in exercise prescription conversations with patients. A group of 20 first-year medical students at Sidney Kimmel Medical College (SKMC) attended a selective course on exercise prescription and the American College of Sports Medicine (ACSM) physical activity guidelines. The course included gamification and case-based learning; students were introduced to fitness-related health issues and discussed how to adapt fitness guidelines for unique patient populations, including geriatric and cardiovascular patients. Cases were supplemented with gym equipment for students to further explore both aerobic and strength components of ACSM guidelines. Students' confidence and knowledge of exercise prescription were assessed before and after the session via the Likert scale and case-vignette multiple-choice questions (MCQs), respectively. These surveys were also distributed to 18 SKMC first-year counterparts who did not participate in the course selection. Based on survey scores, students' post-course self-reported confidence was significantly greater than before the session (p=0.034) and greater than that of students who did not participate in the course (p=0.005). Students' knowledge increased and was significantly higher than that of course non-participants (p=0.018). This course highlighted that gamification and case-oriented education interventions can raise medical students' confidence in fitness in the hopes that they feel more comfortable providing exercise recommendations in the future.

The Dearth of Disability Medical Education and a Partial Solution.

Issue: While over one-quarter of adult Americans have a disability, there is a paucity of disability-specific curricula in American medical schools and residency programs. Potential consequences of this educational dearth include persistent inaccessibility of health care facilities and delivery of inequitable health care to individuals with disabilities. Evidence: Several working groups have proposed disability-specific competencies for health professions education and means by which to integrate them into existing curricula. A limited number of medical schools and residency programs have formally introduced disability-specific materials into their curricula. To our knowledge, however, there are no generalist (internal medicine or family medicine) residency programs that offer specialized training in the clinical care of people with disabilities. Implications: Offering generalist physicians the opportunity to acquire the clinical and cognitive skills required to provide thorough and equitable health care to people with disabilities is critically important. There are too few physiatrists to see to their care needs. In this manuscript, we present a novel concentration in an Internal Medicine residency program in the care of individuals with a variety of disabilities. Our hope is that this work will initiate discussions among educational leaders about how to address the lack of graduate medical education-level training in disability care. We also hope it will afford program directors the opportunity to implement similar concentrations and tracks and will eventually produce a generation of generalists who are well-equipped to help care for people with disabilities.

Single-Dose Radiation Therapy Without Additional Surgery as a Treatment for Heterotopic Ossification Developing After Transfemoral Amputation.

ABSTRACT: Heterotopic ossification is the development of mature lamellar bone in soft tissues. Heterotopic ossification can occur in up to 23% of patients after amputation. Heterotopic ossification is often painful, causing significant dysfunction. While radiotherapy is used to prevent heterotopic ossification before formation, there is a dearth of literature on using radiotherapy to treat existing heterotopic ossification. This case report describes the use of late radiotherapy for the management of existing heterotopic ossification that developed after a transfemoral amputation. A 61-yr-old woman with peripheral artery disease of her bilateral lower limbs status post stenting and ultimately left transfemoral amputation was diagnosed with symptomatic heterotopic ossification limiting her function. Another surgery was not felt to be warranted. She was not improving with medical therapy and was prescribed 800 cGy in one fraction. After treatment, she experienced significant relief in her pain, allowing her to resume physical therapy and use of her prosthesis. There are no other published examples of using radiation alone for treatment of heterotopic ossification formation after transfemoral amputation without surgical revision of the bone formation. Our case shows possible utility in single-dose radiation as a treatment to prevent progression of heterotopic ossification, especially when limiting functional progress.

Intolerance of Uncertainty and Self-Compassion in Medical Students: Is There a Relationship and Why Should We Care?

Managing the uncertainty of clinical practice represents a significant source of stress for clinicians, including medical students transitioning into the clinical workplace. Self-compassion, a strategy to better cope with stress and burnout, may represent a skill that can be leveraged to better prepare learners for the uncertainty inherent in clinical practice. A negative correlation between intolerance of uncertainty and self-compassion has been demonstrated in undergraduate students and in the general population. An examination of this relationship in medical students may help inform future curricular development for addressing burnout in undergraduate medical education. We electronically administered the Intolerance of Uncertainty Short Scale and the Self-Compassion Short Form to 273 third-year medical students from a single institution and analyzed data via regression. A significant negative correlation was found between intolerance of uncertainty and self-compassion (p < 0.0001). Students with higher levels of self-compassion showed lower levels of intolerance of uncertainty. This is consistent with findings in other populations. Our findings offer a starting point for designing training experiences that strengthen student self-compassion to enhance their ability to reconcile the uncertainty they will encounter in clinical practice.

I Don't Have a Diagnosis for You: Preparing Medical Students to Communicate Diagnostic Uncertainty in the Emergency Department.

INTRODUCTION: Diagnostic uncertainty abounds in medicine, and communication of that uncertainty is critical to the delivery of high-quality patient care. While there has been training in communicating diagnostic uncertainty directed towards residents, a gap remains in preparing medical students to understand and communicate diagnostic uncertainty. We developed a session to introduce medical students to diagnostic uncertainty and to practice communicating uncertainty using a checklist during role-play patient conversations. METHODS: This virtual session was conducted for third-year medical students at the conclusion of their core clerkships. It consisted of prework, didactic lecture, peer role-play, and debriefing. The prework included reflection prompts and an interactive online module. The role-play featured a patient complaining of abdominal pain being discharged from the emergency department without a confirmed diagnosis. Students participated in the role of patient, provider, or observer. RESULTS: Data from an anonymous postsession survey (76% response rate; 202 of 265 students) indicated that most students (82%; 152 of 185) felt more comfortable communicating diagnostic uncertainty after the session. A majority (83%; 166 of 201) indicated the session was useful, and most (81%; 149 of 184) indicated it should be included in the curriculum. DISCUSSION: This virtual session requires few facilitators; has peer role-play, eliminating the need for standardized patients; and is adaptable for in-person teaching. As its goal was to introduce an approach to communicating diagnostic uncertainty, not achieve mastery, students were not individually assessed for proficiency using the Uncertainty Communication Checklist. Students felt the session intervention was valuable.

Now Is the Time: A Primer on How to Be a Disability Education Champion in Your Medical School.

ABSTRACT: One in four noninstitutionalized adults in the United States lives with a disability. People with disabilities have frequent interactions with the medical community and the healthcare system yet experience disparities in access and outcomes. The Association of American Medical Colleges has included disability in its definition of diversity as one of the aspects of patient care that may affect health equity. However, training in the lived experience of disability is not always included in medical education. Physiatrists make excellent disability champions in medical schools, given their training and experience in the care of individuals with disabilities. Here, we describe strategies for physiatrists to increase disability education in medical schools and an overview of standards and tools (Liaison Committee on Medical Education standards; Commission on Osteopathic College Accreditation standards; International Classification of Functioning, Disability and Health language; and the Core Competencies on Disability for Health Care Education published by the Alliance for Disability in Health Care Education) physiatrists can use to facilitate interactions with medical school educational leadership. Specific examples are provided along with a framework to guide the development of disability champions in medical schools.

Towards a medical school curriculum for uncertainty in clinical practice.

Uncertainty abounds in the clinical environment. Medical students, however, are not explicitly prepared for situations of uncertainty in clinical practice, which can cause anxiety and impact well-being. To address this gap, we sought to capture how students felt in various clinical scenarios and identify programs they found helpful as they worked through uncertainty in their clerkships to better inform curriculum that prepares them to acknowledge and navigate this uncertainty. This is an observational cross-sectional study of third-year medical students surveyed at the end of core clerkships. The survey consisted of the General Self-Efficacy (GSE) Scale and Intolerance of Uncertainty Scale (IUS). Items asked students to rate preparedness, confidence, and comfort with uncertainty in clinical practice. Items on curricular programs asked students to identify training that prepared them for uncertainty in clerkships, and examined correlations with specific clinical practice uncertainty domains (CPUDs). Spearman's rank-order correlation, Chi-Square, and ANOVA were used to analyze quantitative data. Open responses were analyzed using Braun and Clarke's Framework. Response rate was 98.9% (287/290). GSE was inversely correlated with IUS (p < 0.001). GSE was positively correlated with all CPUDs (p < 0.005). IUS had an inverse correlation with all CPUDs (p < 0.005). Pedagogies with statistically-significant relationships with preparing students for uncertainty, communicating and building relationships with patients during times of uncertainty, and overall well-being included: team debriefs, role plays, case- and team-based learning, story slams, and sharing narratives with peers and faculty (p < 0.05). Qualitatively, students appreciated storytelling, role-modeling of communication strategies, debriefing, and simulations. Strategically immersing specific educational formats into formal curriculum may help cultivate skills needed to prepare students for uncertainty. Clinical debriefs, interprofessional role plays, simulations, communications skills training, instructor emotional vulnerability, storytelling, and peer-to-peer conversations may have the most impact. Further study is required to evaluate their longitudinal impact.