The article in this issue by Minihan and colleagues1 on disability-related training for generalist physicians is a welcome and timely discussion. As Minihan et al point out, pediatricians receive some support in the care of children with disabilities through the school system and through state-based programs. Once individuals have achieved the age of majority, those supports largely vanish. The pool of generalist physicians with expertise in treating adults with chronic disabilities, especially those disabilities originating in childhood, is quite small, so that it is not unusual for such patients to be cared for by pediatricians well into their adulthood.2 Over 40 million individuals in the United States report significant disability, and the prevalence of obesity and adult-onset diabetes in younger cohorts of the general population raises concern that future prevalence of disability may rise much higher.2,3 Moreover, individuals with limitations in their abilities to perform activities of daily living are much higher consumers of medical care as a group than those without such limitations.4 Minihan and colleagues identify the knowledge, attitudes, and skills necessary in training generalist physicians in the care of individuals with disabilities. The authors identify key items in these categories and discuss educational programs to promote their acquisition. Without question, we need to improve the education of generalist physicians in the care of this important and vulnerable section of our population, and Minihan and colleagues make an important contribution toward defining an outline for doing so. Education, however, is not enough.
Even with compassionate, educated generalist physicians, there remain some vexing problems in providing high-quality care for individuals with disabilities: adequate time and facilities, and provider expertise and experience. Individuals with chronic disabilities face a range of problems that may need to be discussed with their physicians. Successful patient-provider collaboration toward managing these problems can easily require far more than the routine time allotted for follow-up primary care visits in a busy practice. Moreover, patients with disabilities may require additional assistance in disrobing for examinations, transferring to the examination table, and dressing after examination. Clinic staffing must be adequate to achieve these tasks safely. In addition, examination equipment must be designed to be accessible. A recent study demonstrated that despite a nearly fivefold difference in annual medical expenditures, the proportion of women with significant cognitive or physical limitations who did not receive a Pap test within the past three years was double that of the population with no disabilities.5 Risk-adjusted capitation payments can, in principle, provide the necessary resources to ensure adequate care for the population with disabilities, but the methodology remains a work in progress.2
For nearly every facet of medicine that has been investigated, volume does matter. Among others, hospital outcomes,6 surgical outcomes,7,8 and medical decision making9 all appear to be improved with increased volumes of experience. For those of us medical professionals who have personally faced a surgical procedure, the first question to the prospective surgeon is, “How many of these have you done?” But in an environment where volume can make such a difference in improving ability, a generalist physician may only encounter a handful of patients with particular disabilities throughout the course of practice.
How, then, can we devise systems of care that will support the generalist physician in the care of these patients? The availability of knowledge on the Internet has aided consumers and professionals alike. However, information is not equivalent to expertise. A natural development in multipractitioner groups of primary care physicians is cultivation of individual practitioners with special interests around disability. Thus, in a group of pediatricians, one or more might take an interest, and receive referrals from colleagues, in the care of children with cerebral palsy. Specialty networks to support primary care physicians can be very effective in providing high-quality, cost-effective care. For example, patients with chronic respiratory failure in France are comanaged between primary care and a respiratory care network.10 How to organize and maintain such expertise so that it is available to patients with disabilities throughout the country will be among the most difficult challenges facing our evolving health care system. Minihan and colleagues have provided us with a good start toward enhancing the education of generalist physicians in the care of persons with disabilities. A blueprint for revamping our medical care delivery systems to support them remains to be drafted.
The author is employed by the National Institutes of Health (NIH).
The opinions in this commentary are those of the author and do not reflect the views of the NIH or of the Department of Health and Human Services.
1 Minihan PM, Robey KL, Long-Bellil LM, et al. Desired educational outcomes of disability-related training for the generalist physician: Knowledge, attitudes, and skills. Acad Med. 2011;86:1171–1178.
2 Institute of Medicine. The Future of Disability in America. Washington, DC: National Academy Press; 2007.
3 Centers for Disease Control and Prevention. Prevalence and most common causes of disability among adults: United States, 2005. MMWR Morb Mortal Wkly Rep. 2009;58:421–426.
4 Yu WW, Ezzati-Rice. T.M. Statistical Brief #81: Concentration of Health Care Expenditures in the U.S. Civilian Noninstitutionalized Population. Medical Expenditure Panel Survey. Rockville, MD: Agency for Healthcare Research and Quality; 2005. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st81/stat81.shtml
. Accessed June 23, 2011.
5 Reichard A, Stolzle H, Fox MH. Health disparities among adults with physical disabilities or cognitive limitations compared to individuals with no disabilities in the United States. Disabil Health J. 2011;4:59–67.
6 Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O'Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med. 2006;355:41–50.
7 Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128–1137.
8 Davies RR, Russo MJ, Hong KN, et al. Increased short- and long-term mortality at low-volume pediatric heart transplant centers: Should minimum standards be set? Retrospective data analysis. Ann Surg. 2011;253:393–401.
9 Israni RK, Shea JA, Joffe MM, Feldman HI. Physician characteristics and knowledge of CKD management. Am J Kidney Dis. 2009;54:238–247.
10 Stuart M, Weinrich M. Integrated health system for chronic disease management: Lessons learned from France. Chest. 2004;125:695–703.