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Competency-Based Curriculum Development to Meet the Needs of People With Disabilities: A Call to Action

Ankam, Nethra S. MD; Bosques, Glendaliz MD; Sauter, Carley MD; Stiens, Steven MD, MS; Therattil, Maya MD, MS; Williams, Faren H. MD, MS; Atkins, Caleb C. MD; Mayer, R. Samuel MD

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doi: 10.1097/ACM.0000000000002686
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Abstract

Medical students need to be taught the skills necessary to take care of people with disabilities, as this disparate and varied group continues to be underserved by the American health care system.1–3 Traditional medical school curricula do not fully address the needs of people with disabilities, and current curricular revisions offer an opportunity for inclusion of disability education. We advocate for inclusion of disability-related topics in current undergraduate medical education student-centered learning tasks, with the expectation that these changes will allow for greater skill and competence in the care of people with disabilities. There are significant gaps in the education of physicians about disability that may contribute to health care disparities experienced by people with disabilities. Instituting our recommended changes will allow medical schools to successfully meet Liaison Committee on Medical Education (LCME) standards and will allow medical students to achieve success in required competencies, thus producing well-rounded, multidimensional physicians who can appropriately care for people with disabilities.

Call to Action

We are an interested group of physician–educators and people with disabilities who assembled at the Association of Academic Physiatrists (AAP) annual meeting in Sacramento, California, in 2016 to form the Task Force on Disability Education for Medical Students to address the problem of insufficient medical education on disability. As physicians who care for people with disabilities and hear their concerns, we were charged by the AAP board of directors to analyze the problem, find solutions through the lens of competency-based education, and advocate for the resolution of these unmet needs.

The Current State of Disability Education

Disability on the rise

People living with disability make up a substantial portion of our nation’s population and contribute to its diversity.4–8 Disability has been defined by the World Health Organization (WHO) as an “umbrella term for impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between the individual (with a health condition) and that individual’s contextual factors (environmental and personal factors).”9 Each individual lives with her or his unique experience of disability as it relates to contextual factors or life situation. Overall, 22.2% of adults in the United States reported some disability as of 2013,4,5 including limitations in cognition, mobility, vision, independent living, or self-care. This prevalence is likely to continue to grow as the population ages6,7 and as chronic conditions take their toll.10 Furthermore, disability is included in the definition of diversity put forth by the Association of American Medical Colleges (AAMC) Group on Diversity and Inclusion, emphasizing the need for comprehensive medical student education on disability.11

People with disabilities are underserved

The U.S. health care system is insufficiently prepared educationally, structurally, and economically to recognize and address the needs of people with disabilities.1–3 Recently, people with disabilities have reported more barriers when accessing care than those who are able-bodied4,12–14 and greater dissatisfaction with the health care that they receive.12 In addition, despite having higher rates of contact with clinicians in every field of medicine due to the prevalence of secondary complications,15–24 people with disabilities report higher levels of unmet health care needs than those without disability and are screened less frequently for preventable conditions.12,14,25–27 Because all physicians will encounter people with disabilities in their practices, it is important that every clinician be able to demonstrate comfort and competence in treating this patient population.28 Studies have shown, however, that medical and health professions students and physicians may be uncomfortable treating, or harbor negative opinions regarding, people with disabilities.29–33 Teamwork is essential for care of people with disabilities, and medical students have been historically inadequately prepared for interprofessional collaboration.34–36 This lack of proficiency in patient and interprofessional communication contributes to omissions, ineffective interventions, and the occurrence of medical complications.34–36 Therefore, medical students can have gaps in competency achievement in recognizing the sequelae of disability and applying principles of regular preventive care for this population.36 Of note, people with disabilities are underrepresented in the physician workforce.11,37

Medical students are undereducated

Despite the pervasive presence of people with disabilities in our health care system, lack of awareness of variety, lived experience, and prognosis with intervention continues to be a challenge in medical education. A decade ago, Holder and colleagues3 used a national survey to estimate that only 20% of medical schools in the United States included disability awareness in their curricula. A survey of curriculum deans conducted in 2015 demonstrated improvement and explored specifics of disability education in the context of each medical school’s curricular design.38 Fifty-two percent of responding deans (39/75) reported a disability awareness program. Of the schools that did not have a disability awareness curriculum, the most common reason for its absence was that no one was advocating for its inclusion.38 In addition, a query of the AAMC Curriculum Inventory and Report (CIR) from 2015–2016 demonstrated that many medical schools did not explicitly address disability in their curriculum (23/134 schools lacked elements addressing disability).39 Training programs without current disability education identified the following content areas, ranked by importance, as ideal for addition to the curriculum: communication skills, examination skills, health care disparities, disability ethics, personal experiences with people with disabilities, legal rights, community resources, and sexual health.38 Education in disability concepts remains underdeveloped, yet sought out, as clear needs have been identified. The addition of such content has few barriers other than lack of advocacy for inclusion in curriculum revisions. Proposed criteria exist for the expected knowledge, skills, and attitudes of physicians caring for people with disabilities; however, the best methods for integrating these concepts still need to be identified.40

Disability curricula often lack modern educational strategies

We conducted literature searches and reviews of academic medical institution websites and consulted via monthly video teleconferences (between February 2016 and December 2017) to establish focus and synthesis of how to address this problem in medical education. Previously completed literature searches of the electronic databases MEDLINE, OVID Healthstar, PsychINFO, Journals@OVID, Scopus, and Google Scholar for educational literature published between 1990 and 2014 using the medical subject headings “disabled persons” and “chronic disease” had been conducted by other researchers in October 2013, March 2014, and January 2016.41 These collections were supplemented with additional literature review by the task force members in 2016 for current and relevant articles. We discussed the literature in the context of creating curricular recommendations for medical schools, including the standards from the LCME and the AAMC Core Entrustable Professional Activities for Entering Residency (Core EPA) initiative.42 The move toward competency-based education is epitomized by the AAMC’s Core EPA pilot program, which describes patient care activities that incoming interns are entrusted to perform on day one of residency.42 All of the Core EPAs have foundational competencies that support students’ ability to perform the activity at an entrustable level for a patient with a disability.

Our analysis indicates that the current undergraduate medical education system does not adequately train students to provide care for people with disabilities.3,43 We noted that most educational methods recorded in the literature were passive instructional methods, such as lectures or patient panel discussions. This conclusion is confirmed in the AAMC CIR report analysis. Of the schools in the report that include disability education in their curriculum, based on the AAMC CIR report, the most common teaching method is lecture format.39 Learning via lecture exemplifies the capability of “knows” on Miller’s pyramid, a recognized model of adult learning using a hierarchy of capabilities starting with knowledge (“knows”) and progressing to competence (“knows how”), performance (“shows how”), and does (“spontaneous action”).44 A focused effort toward integration of disability-related concepts and a more active method of learning at the performance level are needed to address these known deficits in medical education and improve the skills of the future physicians who will care for people with disabilities.

Recommendations

Incorporate the WHO International Classification of Functioning, Disability, and Health

Our literature evaluation reinforced the need for development and incorporation of disability education for medical students to ensure competence of skills. Standard 7 of the LCME discusses recommendations for curricular content and includes societal and cultural competence.45 One method to integrate disability-focused training into an existing curriculum to meet this standard is to implement the biopsychosocial model of care.46 Such a model can help students understand the experience of the patient with a disability from multiple perspectives.47–51 The WHO International Classification of Functioning, Disability, and Health (ICF) (Figure 1) is a model focused on function that considers both medical diagnoses and functional impairments. Use of this model can improve one’s understanding of the ways an individual (with multiple complex medical conditions and comorbidities) interacts with the individual’s contextual factors (including personal and environmental factors that affect function).6,9,49–51 The ICF in particular represents a “merg[ing] of the biomedical and holistic paradigms” across a number of different disabilities.52 The ICF model is designed to be used as a tool for measuring function in the home and community, no matter what diagnosis contributes to a person’s impairment.53 The ICF thus moves the focus from illness to the level of functioning and, in doing so, creates a system that can demonstrate how there can be person-centered life participation despite severe deficits in activity attainment. The ICF mainstreams the experience of disability and recognizes functioning and disability as a universal human experience.9 Using the ICF model enables a paradigm shift in the understanding and teaching of disability concerns; educators and students can recognize disability independent of a diagnosis or medical specialty. We advocate for the incorporation of the ICF in the process of case development, as well as teaching it as a conceptual framework for the students, as this can expand the detail and depth of cases by providing a vocabulary and structure to broaden collaborative, interprofessional, whole-person goal setting and treatment plans (Figure 2).35

Figure 1
Figure 1:
The World Health Organization ICF model. Functioning is an umbrella term that denotes the positive interactions between the individual and their contextual factors (personal and environmental). Disability is an umbrella term that denotes the negative interactions between the individual and their contextual factors. Activity and participation refer to tasks the individual does for themselves and involvement in life situations, respectively. The level of activity limitation or participation restriction can be looked at through the lenses of capacity and performance. Capacity refers to what the individual can do in the idealized setting without environmental barriers, where performance refers to their current function in their own environment. Through this lens, it is clear that impairments and activity limitations do not necessarily lead to disability because they can be compensated for by environmental and personal factors to lead to improved function.9Abbreviation: ICF indicates International Classification of Functioning, Disability, and Health.
Figure 2
Figure 2:
A sample World Health Organization ICF assessment sheet filled out for a sample patient with a stroke. The ICF model allows for development of patient-centered goals by identifying impairments and addressing activity limitations and participation restrictions that are modified by a patient’s personal and environmental factors. In the outlined case, a patient who has significant impairments and activity limitations from a health professional’s standpoint has few activity limitations or participation restrictions from their own perspective when taking into account adaptive devices, positive personal facilitators, and a supportive environment.9,61–63Abbreviation: ICF indicates International Classification of Functioning, Disability, and Health.

Include people with disabilities

Symons and colleagues54,55 reported the outcomes from a comprehensive integrated disability curriculum at the State University of New York at Buffalo. Medical students were introduced to disability topics and people with disabilities in their first year. The first session was introduced with a lecture and “encounters” with people with disabilities and their families. Discussions were fostered about positive and negative interactions with the health care system. In their second year, specific clinical encounters were integrated into students’ learning. In the third and fourth years, additional time was spent with people with disabilities during clerkships, workshops, and additional elective time. The outcome measures used included a questionnaire and self-reported reactions to clinical vignettes. The students who participated in the curriculum reported being more comfortable interacting with people with disabilities than the students in the control group. However, the assumption that improved attitudes lead to better patient care has not yet been established and requires further exploration. Disability curricula require thoughtful evaluation of their efficacy in regard to patient outcomes.

Integrate disability topics into existing skills training and assessment

A fully integrated disability curriculum that includes active classroom learning, clinical and research activities, and community-based experiences would be ideal.53–58 However, we recognize that such a curriculum requires significant resources to implement. Given that learning tasks such as objective structured clinical examinations (OSCEs) can be used to ascertain the skill level of students caring for people with disabilities,36 we created case examples to guide curriculum developers. For the initial implementation of a disability curriculum, we advocate for the modification of cases already being used in established student-centered learning tasks (e.g., case-based learning, problem-based learning, or team-based learning) and OSCE formats, as outlined in Table 1. Table 1 provides examples of opportunities to introduce disability elements into existing curriculum components by Core EPA.42 These learning activity examples allow for the learner to achieve the higher capabilities of Miller’s pyramid and achieve proficiency in understanding and caring for people with disabilities, which is necessary to meet the Core EPAs. Such activities can be applied at any level of training throughout undergraduate medical education in both clinical and preclinical years.47 The proposed changes would not add significant extra time to a school’s curriculum. Attitude assessments alone do not measure the individual student’s skills in data gathering related to disability, nor do they measure the ability of the student to recognize the implications of disability on patient management.59 However, in student-centered learning tasks, cases can be made more complex by the inclusion of disability, bringing the patient’s level of function into discussions of case learning objectives and student assessment. OSCEs can assess students’ recognition of critical disability issues through history taking, physical examination skills, and problem definition.48,60 These learning activities also provide students the opportunity to demonstrate application of the biopsychosocial model of care. Collection of outcome data can further strengthen curricular changes by providing insight into which aspects are most effective with regard to future application of the taught principles.

Table 1
Table 1:
Sample Case Modifications, Mapped to Core EPAs to Include Issues Related to Disabilitya

Identify resources and champions within the community

In medical schools with a paucity of curricula devoted to concepts of disability, the faculty does have the ability to integrate these concepts into existing elements. Because the clinical concerns of people with disabilities span multiple disciplines, many clinicians have the background to address these deficiencies in the curriculum, including but not exclusively specialties such as developmental pediatrics, family medicine, physical medicine and rehabilitation, psychiatry, neurology, geriatrics, and palliative care. The creation and implementation of disability education are not restricted to particular specialties, as the principles are practical and relevant in a variety of clinical settings. There also may be nontraditional resources to create curricula at medical schools. In a recent survey of curricular deans, contributors to disability awareness programs included allied health providers (54%), community group representatives (51%), family members of people with disabilities (35%), and medical students (19%).38 Many of the authors have collaborated with other faculty at their medical schools by recommending changes to the current student-centered learning tasks. For example, disability education was integrated into a problem-based learning case of a person with chronic pain via functional disability scores, interprofessional management, and additional environmental and personal factors added to the history.

Summary

We advocate for disability-focused changes to be made to current student-centered learning tasks to highlight specific learning objectives related to the care of people with disabilities. As a task force, we have mapped sample learning objectives to Core EPAs because we recognize that achieving these Core EPAs cannot be complete without specifically addressing care for people with disabilities. In addition, if the numbers of medical students with disability are increased, we feel confident that students will gain perspective from their peers on treating people with disabilities as well.37 It is particularly important that all medical school graduates demonstrate competence in caring for people with disabilities because this population will likely make up a significant portion of their clinical practice regardless of their eventual specialty.

Acknowledgments: The authors wish to thank Margaret Turk, MD, and the physical medicine and rehabilitation program at State University of New York–Upstate for their shared interest in this topic and for their assistance in identifying relevant articles. The authors wish to thank Amy Schnappinger for her administrative support of the task force and Percival Pangilinan, MD, for his early efforts on this task force.

References

1. Office of the Surgeon General. Office on Disability. Health and wellness for persons with disabilities today. In: The Surgeon General’s Call to Action to Improve the Health and Wellness of Persons With Disabilities. 2005.Rockville, MD: Office of the Surgeon General.
2. Reis J, Breslin M, Iezzoni L, Kirschner K. It Takes More Than Ramps to Solve the Crisis of Healthcare for People With Disabilities. 2004.Chicago, IL: Rehabilitation Institute of Chicago.
3. Holder M, Waldman HB, Hood H. Preparing health professionals to provide care to individuals with disabilities. Int J Oral Sci. 2009;1:6671.
4. Lagu T, Hannon NS, Rothberg MB, et al. Access to subspecialty care for patients with mobility impairment: A survey. Ann Intern Med. 2013;158:441446.
5. Courtney-Long EA, Carroll DD, Zhang QC, et al. Prevalence of disability and disability type among adults—United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:777783.
6. Brault M. Americans With Disabilities: 2010. July 2012. Washington, DC: United States Census Bureau; Report number P70-131.
7. Field MJ, Jette AM; Institute of Medicine Committee on Disability in America. The Future of Disability in America. 2007.Washington, DC: National Academies Press.
8. DeLisa JA, Lindenthal JJ. Commentary: Reflections on diversity and inclusion in medical education. Acad Med. 2012;87:14611463.
9. World Health Organization. International Classification of Functioning, Disability, and Health: ICF. 2001.Geneva, Switzerland: World Health Organization.
10. Esselman P, Berbrayer D, Friedly J, Granger C, Mayer RS. Chronic care education in medical school: A focus on functional health and quality of life. Am J Phys Med Rehabil. 2009;88:798804.
11. Association of American Medical Colleges. About GDI. https://www.aamc.org/members/gdi/about. Accessed January 27, 2019.
12. Gulley SP, Altman BM. Disability in two health care systems: Access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities. Disabil Health J. 2008;1:196208.
13. Iezzoni LI, Frakt AB, Pizer SD. Uninsured persons with disability confront substantial barriers to health care services. Disabil Health J. 2011;4:238244.
14. de Vries McClintock HF, Barg FK, Katz SP, et al. Health care experiences and perceptions among people with and without disabilities. Disabil Health J. 2016;9:7482.
15. Anson CA, Shepherd C. Incidence of secondary complications in spinal cord injury. Int J Rehabil Res. 1996;19:5566.
16. Charlifue SW, Weitzenkamp DA, Whiteneck GG. Longitudinal outcomes in spinal cord injury: Aging, secondary conditions, and well-being. Arch Phys Med Rehabil. 1999;80:14291434.
17. Dorsett P, Geraghty T. Health-related outcomes of people with spinal cord injury—A 10 year longitudinal study. Spinal Cord. 2008;46:386391.
18. Dryden DM, Saunders LD, Rowe BH, et al. Utilization of health services following spinal cord injury: A 6-year follow-up study. Spinal Cord. 2004;42:513525.
19. Gutenbrunner C, Schiller J, Schwarze M, et al. Hannover model for the implementation of physical and rehabilitation medicine teaching in undergraduate medical training. J Rehabil Med. 2010;42:206213.
20. Mitra M, Clements KM, Zhang J, Iezzoni LI, Smeltzer SC, Long-Bellil LM. Maternal characteristics, pregnancy complications, and adverse birth outcomes among women with disabilities. Med Care. 2015;53:10271032.
21. New PW. Secondary conditions in a community sample of people with spinal cord damage. J Spinal Cord Med. 2016;39:665670.
22. Nosek MA, Hughes RB, Petersen NJ, et al. Secondary conditions in a community-based sample of women with physical disabilities over a 1-year period. Arch Phys Med Rehabil. 2006;87:320327.
23. Rasch EK, Magder L, Hochberg MC, Magaziner J, Altman BM. Health of community-dwelling adults with mobility limitations in the United States: Incidence of secondary health conditions. Part II. Arch Phys Med Rehabil. 2008;89:219230.
24. Wilber N, Mitra M, Walker DK, Allen D, Meyers AR, Tupper P. Disability as a public health issue: Findings and reflections from the Massachusetts survey of secondary conditions. Milbank Q. 2002;80:393421.
25. Mahmoudi E, Meade MA. Disparities in access to health care among adults with physical disabilities: Analysis of a representative national sample for a ten-year period. Disabil Health J. 2015;8:182190.
26. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services. Arch Phys Med Rehabil. 2004;85:749757.
27. Iezzoni LI, McCarthy EP, Davis RB, Siebens H. Mobility impairments and use of screening and preventive services. Am J Public Health. 2000;90:955961.
28. Long-Bellil LM, O’Connor DM, Robey KL, et al.; Alliance for Disability in Health Care Education. Commentary: Defining disability in health care education. Acad Med. 2011;86:10661068.
29. McKinley WO, Gittler MS, Kirshblum SC, Stiens SA, Groah SL. Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management. Arch Phys Med Rehabil. 2002;83(3 suppl 1):S58S64, S90.
30. Tervo RC, Palmer G, Redinius P. Health professional student attitudes towards people with disability. Clin Rehabil. 2004;18:908915.
31. Bu P, Veloski JJ, Ankam NS. Effects of a brief curricular intervention on medical students’ attitudes toward people with disabilities in healthcare settings. Am J Phys Med Rehabil. 2016;95:939945.
32. Byron M, Cockshott Z, Brownett H, Ramkalawan T. What does “disability” mean for medical students? An exploration of the words medical students associate with the term “disability.” Med Educ. 2005;39:176183.
33. Jain S, Foster E, Biery N, Boyle V. Patients with disabilities as teachers. Fam Med. 2013;45:3739.
34. Stineman M, Kurz AE, Hahn H, Stiens S. O’Young B, Young MA, Stiens SA. Communication strategies for rehabilitation medical professionals. In: Physical Medicine and Rehabilitation Secrets. 2008.3rd ed. St. Louis, MO: Mosby.
35. Snyman S, Von Pressentin KB, Clarke M. International Classification of Functioning, Disability and Health: Catalyst for interprofessional education and collaborative practice. J Interprof Care. 2015;29:313319.
36. Brown RS, Graham CL, Richeson N, Wu J, McDermott S. Evaluation of medical student performance on objective structured clinical exams with standardized patients with and without disabilities. Acad Med. 2010;85:17661771.
37. Iezzoni LI. Why increasing numbers of physicians with disability could improve care for patients with disability. AMA J Ethics. 2016;18:10411049.
38. Seidel E, Crowe S. The state of disability awareness in American medical schools. Am J Phys Med Rehabil. 2017;96:673676.
39. Association of American Medical Colleges. Curriculum inventory report: Coverage of disability education content in U.S. medical schools. AAMC curriculum inventory, 2015–2016. https://www.aamc.org/initiatives/cir/curriculumreports. Accessed March 10, 2017.
40. Minihan PM, Robey KL, Long-Bellil LM, et al.; Alliance for Disability in Health Care Education. Desired educational outcomes of disability-related training for the generalist physician: Knowledge, attitudes, and skills. Acad Med. 2011;86:11711178.
41. Atkins C, Ahmad O, Mudda B, Liju J, Turk M. Disability within healthcare professionals curricula: A mapping review. Am J Phys Med Rehabil. 2016;95:a34.
42. Englander R, Aschenbrener C, Call S, et al. Core Entrustable Professional Activities for Entering Residency (updated). https://www.mededportal.org/icollaborative/resource/887. Updated May 28, 2014. Accessed January 27, 2019.
43. Gibson J, Lin X, Clarke K, Fish H, Phillips M. Teaching medical students rehabilitation medicine. Disabil Rehabil. 2010;32:19481954.
44. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9 suppl):S63S67.
45. Liaison Committee on Medical Education. Functions and structure of a medical school. http://lcme.org/publications. Published March 2017. Accessed January 29, 2017.
46. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535544.
47. Stiens SA, Berkin D. A clinical rehabilitation course for college undergraduates provides an introduction to biopsychosocial interventions that minimize disablement. Am J Phys Med Rehabil. 1997;76:462470.
48. Stiens S, O’Young B, Young M. O’Young B, Young MA, Stiens SA. Person-centered rehabilitation: Interdisciplinary intervention to enhance patient enablement. In: Physical Medicine and Rehabilitation Secrets. 2008.3rd ed. St. Louis, MO: Mosby.
49. Suls J, Green PA, Davidson KW. A biobehavioral framework to address the emerging challenge of multimorbidity. Psychosom Med. 2016;78:281289.
50. Schlenz AM, Schatz J, Roberts CW. Examining biopsychosocial factors in relation to multiple pain features in pediatric sickle cell disease. J Pediatr Psychol. 2016;41:930940.
51. Wijenberg ML, Stapert SZ, Köhler S, Bol Y. Explaining fatigue in multiple sclerosis: Cross-validation of a biopsychosocial model. J Behav Med. 2016;39:815822.
52. Stineman MG. The clinician’s voice of brain and heart: A bio-psycho-ecological framework for merging the biomedical and holistic. Top Stroke Rehabil. 2011;18:5559.
53. Stucki G. International Classification of Functioning, Disability, and Health (ICF): A promising framework and classification for rehabilitation medicine. Am J Phys Med Rehabil. 2005;84:733740.
54. Symons AB, McGuigan D, Akl EA. A curriculum to teach medical students to care for people with disabilities: Development and initial implementation. BMC Med Educ. 2009;9:78.
55. Symons AB, Morley CP, McGuigan D, Akl EA. A curriculum on care for people with disabilities: Effects on medical student self-reported attitudes and comfort level. Disabil Health J. 2014;7:8895.
56. Saketkoo L, Anderson D, Rice J, Rogan A, Lazarus CJ. Effects of a disability awareness and skills training workshop on senior medical students as assessed with self ratings and performance on a standardized patient case. Teach Learn Med. 2004;16:345354.
57. Tracy J, Iacono T. People with developmental disabilities teaching medical students—Does it make a difference? J Intellect Dev Disabil. 2008;33:345348.
58. Woodard LJ, Havercamp SM, Zwygart KK, Perkins EA. An innovative clerkship module focused on patients with disabilities. Acad Med. 2012;87:537542.
59. Morris H, Ryan C, Lauchlan D, Field M. Do medical student attitudes towards patients with chronic low back pain improve during training? A cross-sectional study. BMC Med Educ. 2012;12:10.
60. Long-Bellil LM, Robey KL, Graham CL, Minihan PM, Smeltzer SC, Kahn P; Alliance for Disability in Health Care Education. Teaching medical students about disability: The use of standardized patients. Acad Med. 2011;86:11631170.

References cited only in Figure 2

61. ICF Research Branch. Template ICF assessment sheet. https://www.icf-research-branch.org/download/category/17-icf-based-case-studies. Published 2016. Accessed January 27, 2019.
    62. Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil Med. 2008;44:329342.
      63. ICF Research Branch. The ICF assessment sheet. https://www.icf-casestudies.org/introduction/introduction-to-icf-based-documentation-tools-and-rehab-cycle-2/the-icf-assessment-sheet. Updated 2018. Accessed January 27, 2019.
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