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The Challenge of Teaching Rehabilitative Care in Medical School

Currie, Donald M. MD; Atchison, James W. DO; Fiedler, Irma G. PhD

Special Theme: Medical Education in the Ambulatory Setting: ARTICLES

Rehabilitative care has gained importance because the population is aging, and improved acute and chronic medical care saves and prolongs lives but leaves some patients with temporary or permanent physical impairments. However, despite its importance, the teaching and learning of rehabilitative care in medical school lag behind medical education relating to acute and chronic care. The authors analyze the broad scope of rehabilitative care and the need to include it in the medical school curriculum. They also discuss advantages for students and their patients of learning rehabilitative care in the undergraduate curriculum and suggest methods to improve teaching it.

Dr. Currie is associate professor, Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio; Dr. Atchison is associate professor and chief, Department of Orthopaedics and Rehabilitation, Division of Physical Medicine and Rehabilitation, University of Florida College of Medicine, Gainesville; and Dr. Fiedler is associate professor, Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee.

Correspondence should be addressed to Dr. Currie, Department of Rehabilitation Medicine—Mail Code 7798, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900; e-mail: 〈currie611@pol.net〉. Reprints are not available.

The authors especially acknowledge Joel A. DeLisa and Charles Levy for their suggestions and contributions to this article.

Dr. F's presentation to the third-year medical student class demonstrated a systematic approach to patients with spinal cord injuries that would enable the students to apply basic science knowledge as expert clinicians do. From now on they would be able to use a similar approach to manage any complex patient with multiple interacting problems. Dr. F presented sitting in a wheelchair, because he himself has quadriplegia as a result of a permanent spinal cord injury sustained as a high school student. He concluded his lecture showing the class two brief videotapes. The first showed how he transfers from his wheelchair into his pickup truck and uses hand controls for his daily drive to the spinal cord injury center where he works. The second projected ultrasonic images of the child he and his wife were expecting in three months, the first child in this large city conceived by a quadriplegic father using a new fertility technique.

Even after the assigned class time, the students surrounded him to ask questions. Dr. F was a living example of how a whole-person patient-centered approach to medicine could help someone with an incurable, catastrophic disability achieve a satisfying quality of life. He was also a role model of a physician who treated patients as whole persons with families, jobs, and dreams, not just diseases.

At another medical school, first-year medical students observed a demonstration being conducted by physical therapists and a physiatrist. (A physiatrist is a physician certified in physical medicine and rehabilitation, or PM&R, the specialty dedicated to the development and practice of the field of “rehabilitative care.”) The students watched intently as individuals with paraplegia, hemiplegia, and quadriplegia transferred to and from wheelchairs, and gasped when one of the patients walked with the aid of assistive technology. The elective learning experience for first- and second-year medical students was one of a six-part series of grant-funded lunch presentations called Primary Care for the Disabled. Interactive demonstrations with persons with disabilities were spaced throughout the first two years of medical school. Students learned about “disability etiquette” and barriers faced by disabled individuals through role-playing interviews of inappropriate and appropriate interactions. The 300 students who participated showed a statistically significant gain in scores on the Attitudes Towards Disability Scale, and submitted favorable subjective evaluations.1 Other results included a higher level of interest in rehabilitation medicine compared with that in previous years and requests from several students to “shadow” a physiatrist during his or her daily duties.

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THE SCOPE AND RELEVANCE OF REHABILITATIVE CARE

The Liaison Committee on Medical Education (LCME) uses the term “rehabilitative care” in its description of content that must be included in the clinical curricula of all medical schools.2 Related to this curricular requirement, the LCME standards state, “Students must have opportunities to gain knowledge in those content areas that incorporate several disciplines in providing medical care, for example, the care of the elderly and disabled.”

The purpose of this article is to explore the scope of the knowledge, skills, and attitudes encompassed by the term “rehabilitative care,” to grasp the importance of this branch of medicine in current medical practice and education, to analyze shortcomings in the education of medical students in this area, and to suggest ways to improve the learning and teaching of rehabilitative care.

Rehabilitative care includes the study of the ways illnesses and injuries interfere with human function and strategies available to help patients overcome or circumvent barriers to optimal function. The diagnostic categories of patients who benefit from rehabilitative care span a broad spectrum that ranges from world-class athletes with musculoskeletal disorders that would be insignificant except to those testing the limits of human performance to persons struggling to regain and maintain independence following catastrophically disabling illnesses or injuries. In every case, rehabilitative care involves helping patients achieve their optimal levels of function and quality of life by minimizing their deficits and maximizing their abilities. Patients and treatment goals are considered from a lifelong perspective. While the variability of diagnostic categories causes rehabilitative care to overlap several disciplines, the constant emphasis on function unifies the content areas under the global concept of rehabilitative care.

The World Health Organization (WHO) and PM&R specialty organizations have helped define the scope of rehabilitative care. Their publications show a convergence of key elements of rehabilitative care with current emphases in medical education, for example3–7:

  • ▪ Approaching patients as whole persons in the context of their families and communities
  • ▪ Emphasizing the concept of quality of life
  • ▪ Measuring treatment outcomes, using criteria that quantify human function
  • ▪ Using teams of caregivers who collaborate to extend the reach of traditional acute, chronic, and continuing medical care
  • ▪ Promoting health and preventing disease, injury, and disability
  • ▪ Preparing physicians to participate in issues concerning health care and public policy

The WHO's publication International Classification of Impairment, Disability, and Handicap recognizes an inherent hierarchy of human function.3Impairment is the disruption of normal physiologic function of tissues, organs, and systems, and the traditional medical model is directed toward alleviating impairments. Disability is a restriction or lack of ability to perform ordinary activities, particularly mobility, communication, and activities of daily living, within the range considered normal for a human being. Handicap refers to a disadvantage that limits or prevents an individual's performance of a role that is normal, considering the individual's age, sex, culture, and unique social factors. Thus, disability and handicap refer to the disruption of uniquely human functions that may be caused by impairments, but may also be due to non-physiologic causes, such as the prejudices of other persons or architectural barriers.

The Undergraduate Education Committee of the Association of Academic Physiatrists developed a white paper outlining rehabilitative care objectives all medical students should achieve by the time they graduate from medical school.6 The authors noted the increasing number of survivors of potentially deadly catastrophes and illnesses as a result of excellent acute medical and surgical care. These patients need rehabilitative care because they “have been left with chronic pain or disability as sequelae.” The authors express the opinion that “the acute care approach has led to a fragmentation of medical care into focused interventions by specialists with little attention to the impact of the illness or injury on the function of the individual as a whole. The current emphasis on primary care and outcome studies makes exposure of all medical students to the approach to care embodied by PM&R particularly important.”

Bloch et al. discussed the benefits of teaching evaluation and management strategies typical of rehabilitative care to “undifferentiated” medical students regardless of their ultimate career paths, since virtually all physicians treat patients with rehabilitative needs.7 Specifically, students should learn to extend the history and physical examination to:

  • ▪ Include evaluation of function and impact on quality of life
  • ▪ Consider how the natural histories of common maladies predictably lead to medical complications, disabilities, or handicaps
  • ▪ Employ measures to prevent or ameliorate anticipated complications
  • ▪ Learn to place the medical needs of every patient they see in the context of the whole person, his or her family, and society—a key tenet of patient-centered medicine8

Because PM&R is perhaps the most team-oriented specialty, PM&R case studies can be used to demonstrate the power of interdisciplinary team—oriented management to reach optimal treatment outcomes. The communication, leadership, team-building, and conflict management skills students learn can be applied in any practice setting.

The measurement of function is the key to quantifying the outcomes of treatments for many conditions. Students can apply knowledge of the functional assessment tools and expertise of allied health professionals to assess the outcomes of medical, surgical, or rehabilitative treatments in diverse patients and populations.

Disability can be studied as a major public health issue of increasing importance due to the growing populations of older adults and survivors of formerly lethal traumatic events or diseases. Persons with disabilities can be used as an example of a population with special primary care needs.9

DeLisa and Walsh have suggested revisions to the reports of the Medical Student Objectives Project of the Association of American Medical Colleges so that the objectives apply better to persons with disabilities or chronic illnesses.10 They recommend revised objectives for medical students in these areas:

  • ▪ Determining and measuring quality of life and satisfaction with life as defined and experienced by patients themselves
  • ▪ Awareness of methods to define successful and worthwhile treatment outcomes
  • ▪ Methods to avoid medical complications and secondary conditions over a person's life span, especially in those with disabilities or chronic illnesses

Students who incorporate these objectives into their practices will better meet the needs of patients as whole persons throughout their careers, regardless of which specialties they choose.

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THE STATE OF THE ART

Various lines of investigation suggest that the teaching and learning of rehabilitative care lags behind other aspects of acute and chronic care in medical school curricula.9–14

One line of evidence concerns faculty members' qualifications and responsibilities to teach rehabilitative care. A study that surveyed PM&R departments with accredited residency programs suggests physiatrists are underutilized in developing undergraduate courses in rehabilitative care and participating in other courses in which medical students should learn rehabilitative care.11,12 This study also noted that the body of knowledge constituting rehabilitative care is fragmented throughout the curriculum, a barrier to its cohesive incorporation.

Another line of evidence is a perception by practicing generalist physicians of deficiencies in their knowledge and capabilities in components of rehabilitative care. Primary care physicians participated in a survey asking them to choose areas of perceived deficiency in their training to enhance an undergraduate PM&R clinical rotation.13 The respondents highlighted musculoskeletal pain problems as their most strongly perceived deficiencies. The results suggested specific topic areas in which teaching of medical students can be improved, especially for those who intend to become primary care physicians.

Information from persons with the most severe disabilities also suggests a need for better training in rehabilitative care. As a group, these individuals require more medical care than the general population, yet it is difficult for them to find physicians who can comfortably and skillfully provide their primary medical care.9,14

Although these lines of evidence are indirect, they all point in the same direction—medical students do not learn enough rehabilitative care. Since the numbers of persons who need rehabilitative care will increase as the population ages and as medical care improves, the need for physicians in most specialties who can apply the principles of rehabilitative care can be expected to increase.

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THE TEACHING OF REHABILITATIVE CARE

We have written broad objectives for an ideal curriculum in rehabilitative care based on our analysis of the references cited in this article (see Appendix A). These objectives form the foundation for a rehabilitative care curriculum. Any medical school could use these objectives as a starting point to guide the development and refinement of its rehabilitative care curriculum. Students should learn the theoretical bases for the topics spanned by these objectives and learn to apply the principles in various clinical settings as they pass through the four years of the medical school curriculum.

Basic scientists and clinicians who already teach medical students should incorporate rehabilitative care into their courses in all four years of the curriculum. In schools with PM&R departments, course directors, curricular committees, and deans should seek and use the expertise of physiatrists who are members of the faculty. Physiatrists should be involved in faculty development programs to hone their skills in teaching and curriculum development. Physiatrists should also share their knowledge by participating in faculty development of basic scientists and generalist and specialist clinicians.

Creative ways of extending capabilities to teach rehabilitative care should be tried and studied. These could include the use of PM&R specialists from the community, PM&R faculty from other medical schools as consultants or visiting faculty, distance learning technology, and information technology to share the best curricula and teachers in rehabilitative care across geographic boundaries. Physician and non-physician faculty members from other departments can be excellent teachers of the principles of rehabilitative care. In addition to medical school basic science and clinical faculty, these should include non-physician members of the rehabilitation team, e.g., physical and occupational therapists, rehabilitation nurses, speech—language pathologists, psychologists, social workers, and recreation therapists. These members of the rehabilitation team can be incorporated on teaching rounds and in clinics where medical students are learning to care for patients in many generalist and specialist clerkships and training sites. Selected persons with disabilities can make excellent teachers for medical students. In addition to the usual venues, a PM&R or rehabilitative care club can be used to allow medical students access to any of these potential teachers or to learn rehabilitative care from each other.

The value of PM&R referrals should be demonstrated during traditional clinical clerkships, with physiatrist faculty members making themselves available for consultations with students. Structured rehabilitative care experiences should be made available to students on clinical clerkships, both during required PM&R clerkship time and embedded in the traditional clerkships.

Appendix B, which we also wrote, shows how the topics that constitute the rehabilitative care curriculum could be incorporated into a traditional medical school curriculum.

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RECOMMENDATIONS

Wide agreement exists that it is important to train medical students in rehabilitative care for the benefit of patients treated in most specialties, including the generalist specialties. We suggest that medical schools can most efficiently improve the teaching of rehabilitative care for their students by taking the following steps.

Each medical school has the responsibility to study the effectiveness of its curriculum in preparing its students for rehabilitative care and to modify the curriculum to achieve this goal. The teaching of rehabilitative care should be embedded throughout the curriculum. A constant challenge will be to define and keep abreast of the status of rehabilitative care in the curriculum to avoid fragmentation. The content, location in the curriculum, and responsibility for teaching the components of rehabilitative care should be clearly specified.

Standardized tests for medical students, such as the U.S. medical licensing examinations, include items related to rehabilitative care. These items must be monitored with feed-back to faculty, especially those charged with curriculum enhancement. Faculty-developed tests should also include items related to rehabilitative care. Appropriate emphasis on the principles of rehabilitative care on examinations will help focus the priorities of students, teachers, and curriculum managers as they learn and teach rehabilitative care.

The impact of function in personal activities and participation in society should be woven into the basic science curriculum as students learn about the structure and physiology of the human body in health and disease. When problem-based learning cases are developed and used by students, rehabilitative aspects of the cases should be highlighted. Students should learn of the salutary effects of rehabilitative principles and techniques to benefit the patient's function as a human being, even when cure is not possible. The elements of rehabilitative care should be presented during didactics and reinforced as students see patients during their clinical clerkships. Faculty for the clinical clerkships should seek assistance from the other teaching resources suggested earlier.

Physiatrists and other specialists should disseminate and develop more curricular tools for teaching rehabilitative care to medical students. Much of this curriculum is amenable to informatics technology, with the best tools being made available to all, especially in those medical schools without a department. Instructional materials are available through the Association of Academic Physiatrists and other organizations whose memberships include academic physiatrists.

The beneficiaries of improved medical education in rehabilitative care will be the patients our medical students serve throughout their careers.

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REFERENCES

1. Sabharwal S, Fiedler IG. Increasing disability awareness of medical students [abstr]. Am J Phys Med Rehabil. 2000;79:205–6.
2. Council on Medical Education of the American Medical Association, the Association of American Medical Colleges, the Canadian Medical Association, and the Association of Canadian Medical Colleges. Functions and Structure of a Medical School: Accreditation and the Liaison Committee on Medical Education: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree (revisions and amendments to 1985 edition of Functions and Structure of a Medical School). Washington, DC: Association of American Medical Colleges and the American Medical Association, 1998:14.
3. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps: A Manual of Classification Relating to the Consequences of Disease. Geneva, Switzerland: World Health Organization, 1980. (Updated version at 〈http://www3.who.int/icf/icftemplate.cfm〉, accessed 4/8/02.)
4. Braddom, RL (ed). Physical Medicine & Rehabilitation. Philadelphia, PA: W. B. Saunders, 1996.
5. DeLisa JA, Gans BM (eds). Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, PA: Lippincott—Raven, 1998.
6. Tuel SM, Meythaler JM, Penrod LE. Educational goals and objectives in physical medicine and rehabilitation for the medical school graduate. Am J Phys Med Rehabil. 1996;75:149–51.
7. Bloch RM, Blake DJ, Fiedler IG. Integration of physical medicine and rehabilitation into the undergraduate medical curriculum. Am J Phys Med Rehabil. 1996;75:242–3.
8. Stewart M. Patient-Centered Medicine: Transforming the Clinical Method. Newbury Park, CA: Sage Publications, 1995.
9. Currie DM. Primary care for persons with disabilities: the physiatrist's perspective. Am J Phys Med Rehabil. 1997;76(Primary Care for Persons with Disabilities suppl):S25–S29.
10. DeLisa JA, Walsh N. Are we overlooking the needs of the disabled? Acad Med. 1999;74:853–4.
11. Fiedler I. Undergraduate education: Status of PM&R. AAP Newsletter. 1996 Summer;14(2):22.
12. Fiedler I. Undergraduate education: status of PM&R [abstract]. Am J Phys Med Rehabil. 1996;75:154.
13. Hettle M, Braddom RL. Curriculum needs in physical medicine and rehabilitation for primary care physicians: results of a survey. Am J Phys Med Rehabil. 1996;74:271–5.
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APPENDIX A

Educational Objectives in Rehabilitative Care

  1. Students should be able to define and apply the concepts of human function and quality of life, impairment, disability, and handicap. Application would include measurement of these parameters using standardized instruments when such measurements are relevant to evaluate and manage patients, monitor the efficacy of treatments, or prevent further losses of functional abilities.
  2. In routine clinical evaluations, students should include items related to the functioning of their patients in their usual environments and roles, document the findings in the medical records, and develop treatment plans directed toward alleviating impairments, disabilities, and handicaps.
  3. Students should understand and appreciate the power of a functional-outcomes—based approach. They should be able to apply this approach to improve outcomes as they manage patients with various diagnoses.
  4. Students must exhibit attitudes of empathy accompanied by a satisfactory comfort level with patients with chronic illnesses and disabilities.
  5. When patients present with the major diagnostic categories of illness in which rehabilitative care is necessary for an optimal outcome, students should understand and be able to apply relevant rehabilitative care evaluation and management strategies throughout the course of illness. Examples of these diagnostic categories include (but are not limited to) disorders of the central and peripheral nervous systems; arthritis, musculoskeletal injuries, and related conditions; pain; cardiovascular, pulmonary, and renal diseases; amputations; and the global health problems that may be associated with advancing age.
  6. Students must be aware of strategies to prevent health problems in their patients. Two aspects of prevention are especially encompassed by rehabilitative care: prevention of injury in occupational and industrial medicine and prevention of predictable problems based on knowledge of the “natural history” of a disorder. Preventable sequelae should be highlighted whenever common disorders are studied in the curriculum.
  7. In addition to learning how to prescribe medications and do procedures, all students should gain some knowledge and practical experience prescribing physical medicine modalities and technology that can improve their patients' functional outcomes. At a minimum these should include heat, cold, therapeutic ultrasound, wheelchairs, basic orthoses and splints, and simple adaptive aids for activities of daily living.
  8. Psychosocial issues relevant to rehabilitative care include the concepts of how social and cultural circumstances affect health and perception of usefulness in society as well as how chronic illness, pain, and disability affect the patient, the family, and the community. Managing the total medical needs of patients includes consideration of these psychosocial and cultural issues, including interventions to help the patients adapt to disabling conditions that cannot be cured.
  9. As they formulate treatment plans, students must develop skills in consulting, communicating with, working with, and using the skills of members of the rehabilitation team and related health care resources. These resources include community agencies and reimbursement sources for health care as well as traditional rehabilitation team members.
14. Mitka M. Enabling students to deal with the disabled. JAMA. 1999;281:595–6.
© 2002 Association of American Medical Colleges