Koerber S, Rea S, Jone S, Lemmieux A, Mendez J. Improving disability education in medical school curricula for health equity. HPHR. 2021;44.
Medical students are more adequately prepared to engage with patients with disabilities when they receive interdisciplinary and immersive learning experiences during medical school. This paper highlights the results of a research study that demonstrated the potential of integrative service learning programs to improve medical education and health care for the disability community. In the described study, integrative service learning for medical students was found to reduce medical student bias, improve patient-provider communication, and assist patients and their families with navigating the healthcare system. This paper also presents an avenue for which similar programs can be widely adopted throughout medical education into equitable and innovative clinical models. These programs could allow improved health care and health outcomes for people with disabilities. By creating medical education programs that include integrative service learning, community participation, and clinical opportunities, medical schools across the country can continue improving their disability curricula for medical students.
Individuals with developmental disabilities face health disparities that are rooted in a historical context of exclusion and discrimination.1,2 Heightened attention and interventions for social determinants of health, however, can result in improved health outcomes for people with disabilities. These social determinants include but are not limited to health outcomes, insurance status, transportation, education, internet access, and unemployment. 3,4 People with disabilities have also recently been disproportionately affected by COVID, further highlighting health inequities in this population.3,4
Medical education has a responsibility to prepare physicians to treat people of all identities and abilities. Although the accrediting body for US medical schools broadly calls for education on cultural biases and cultural competency, there are no formal requirements for development and adoption of curriculum on disabilities beyond clinical identification and diagnosis.5 Recent studies have reported that only 34 percent of medical students had disability-specific education during their medical education6, and 80 percent of students who did receive training believed that it was inadequate.7 Furthermore, a survey of physicians in the US found that most physicians did not have knowledge of their patient responsibilities under the Americans with Disabilities Act, suggesting legal and structural barriers to accessible patient care for those with disabilities.8 However, disability and rehabilitation topics that have been implemented have demonstrated success in educating students on terminology in disability health, disability laws, community resources, and communication skills, as well as improving attitudes toward people with disabilities.9-14 Both simulated and real direct patient encounters with this population have also demonstrated improved medical student comfort, skills, and knowledge needed to appropriately care for a patient with a disability.15-20 Therefore, improved and intentional implementation of specific curricula topics may improve health disparities and health outcomes for the disability population.
The Wayne State University School of Medicine (WSUSOM) in Detroit, Michigan serves a unique patient population of many diverse backgrounds and identities. The topic of this commentary is a student-run developmental disabilities outreach program in Southeast Michigan, called ARIE (named after an unknown donor). This commentary will summarize findings from the ARIE program and provide an example of how other medical schools can create similar programs to reduce health disparities for people with disabilities.
The ARIE program was implemented 7 years ago, with approximately 50 first- and second-year medical student volunteers participating annually. Students are paired with a family who has a child with a developmental disability in a 2:1 ratio of students to children. Families are recruited and compensated for participation through the Michigan Developmental Disabilities Institution (MI-DDI) at Wayne State University. Students are provided with a two-hour didactic session from MI-DDI on developmental disabilities, social determinants of health, and person-first and identity-first language, which prepares them for interactions with the families.
The families and students engage in a phone call, two in-home visit sessions, and an end-of-program celebration, which allow several opportunities for medical students and families to build meaningful relationships. Additionally, the families complete multiple quantitative and qualitative assessments including the 11-question trust scale adapted from the Wake Forest Physician trust scale, and students complete the Medical Students Perceptions of Disability and Definitions and Criteria Associated with Disabilities Assessments (MSPDA).21,22 Students are able to learn more about developmental disabilities, lifestyles of the families, and obstacles the families experience in accessing healthcare. Simultaneously, the students help connect the family to community resources or assist in navigation of the complex healthcare system.
Results from the ARIE program have been incredibly positive for medical students and families. The diagnosed disabilities over the past seven years include autism, cerebral palsy, Down Syndrome, and fetal alcohol syndrome, and other demographics are reported elsewhere.23 Through outcomes measured by pre- and post-surveys of both students and families, the ARIE program has served as an essential link between families and the healthcare system. Families demonstrated increased therapeutic alliance with their providers after participation in the program, and many have explained to medical students the value of a physician who truly listens, empathizes, and respects those with disabilities.23 Families are better able to gain community support and connect with other families who have a child with a developmental disability. After participation in the program, medical students also demonstrated improved empathy and attitudes toward patients with disabilities and gained confidence in physician-patient communication.23 Furthermore, medical student participation in this integrative service learning opportunity allows students to develop tools for advocacy and policy. Medical students are taught to identify gaps in care by observing existing health disparities that families experience in the community, and then bring forward solutions to these disparities. This occurs through collaboration with ARIE, MI-DDI, the School of Medicine, and our local American Medical Association policy writing organization.
Interdisciplinary care results in improved health outcomes for individuals with disabilities.24 An annex of this notion has prompted the development of JAYDA (Joining Adults & Youth with Disabilities through Access), an interdisciplinary care clinic focused on caring for adults with disabilities, with a particular focus on the transition years (18-26). Integrative service learning has been shown to be more beneficial than classroom learning, and as previously discussed, direct interactions with the disability community have improved medical student attitudes, communication, and knowledge.15-20,25 The goal for our medical school is to have all students rotate in the JAYDA clinic, and as a component of the clinic rotation, also participate in the ARIE program. The ARIE program combined with participation in the JAYDA clinic has the potential to reduce health disparities for those with disabilities through direct exposure to the disability community, in combination with didactic learning sessions and patient panels. Participation in both ARIE and JAYDA will allow students to optimize their exposure to patients with disabilities and learn how to engage with this population both professionally and personally.
Although participation in the ARIE program and developing JAYDA clinic is currently voluntary, all medical students should be required to participate in the future, expanding their understanding of biases and difficulties faced by the disability community. In an effort to address this issue, WSUSOM has begun to offer a one-hour lecture followed by an experiential component for all second-year medical students. The experiential component is an introduction to the needs expressed by family members to services, adaptable equipment, and other resources. The next step is to have all medical students who rotate at the JAYDA clinic first complete participation in the ARIE program. The ARIE program serves as a foundation for working with children with disabilities in the community, and students will continue expanding their medical and professional knowledge during their time in the clinic.
Medical students will be more adequately prepared to engage with those with disabilities through integrative clinical learning experiences, advocacy, and comprehensive didactic learning. It is hypothesized that programs such as the ARIE program have the potential to better serve the disability population through access, healthcare and social services navigation, interdisciplinary care, and needs assessments. Programs like ARIE also allow the disability community to play a direct role in teaching future healthcare providers about unique health challenges and how to confront bias against those with disabilities. We aim for this program to serve as a model for dissemination and replication throughout medical education to reduce health disparities for people with disabilities.
We thank the Michigan Developmental Disabilities Institution (MI-DDI) at Wayne State University, Sharon Milberger, Sc.D., Ms. Elizabeth Janks M.S.W., and Jennifer Mendez, Ph.D., at Wayne State University School of Medicine (WSUSOM) for their continued support of this important community program and student organization. We also would like to acknowledge the dozens of families and students who participate in ARIE each year.
The author(s) have no relevant financial disclosures or conflicts of interest.
Dr. Rea is a recent graduate of an MD MPH program at the Wayne State University School of Medicine in Detroit, Michigan. She is entering a physical medicine and rehabilitation residency program. Her interests include pediatric rehabilitation, health equity, social justice, and health policy.
Mr. Jones is an MD MBA student at the Wayne State University School of Medicine in Detroit, Michigan.
Dr. Lemieux is a psychiatry resident in Detroit, Michigan.
Dr. Mendez is an associate professor in Internal Medicine – Geriatrics in Detroit, Michigan. She has led the award-winning Service Learning program at the Wayne State University School of Medicine and co-directs the Community Engagement Elective and the Scholarly Concentration on Policy, Advocacy and Community Health.