Ruedrich et al.’s (1) article is a survey of adult psychiatry residents completing a rotation focused on intellectual disability/developmental disability (ID/DD) patients and serves as an educational outcomes assessment for this particular training program. The article is one of a growing body of literature that recognizes this patient group as being underserved and requiring specific knowledge and skills to effectively address their physical and mental health needs.
Patients with ID/DD are a significant health care population with an increased need for community based services. With the population in the United States at over 300 million and estimates of 2% of the population having significant intellectual disabilities, over 6 million people with ID/DD have special needs for their health care, as well as for their education, housing, and vocational training. Estimates of total spending in 2003 for persons with ID/DD were $34.6 billion with expected increased expenditures in the future. People with ID/DD have an increasing average lifespan of 66 years, and within the last 25 years, over 100,000 people have been discharged from state ID/DD facilities into community based facilities, leading to a significantly increased presence in the community. Rates of psychiatric disorders within the ID/DD population are estimated to be 3–4 times those of the general population. Recognition of these significant needs was a part of Dr. Satcher’s effort as Surgeon General, as he led a nationwide effort to address health care disparities for those with ID/DD in 2001.
Considering the number of persons with ID/DD, the increasing role of community placements, and the prolongation of lifespan, an increasing focus on preparing physicians to address this need is appropriate. This issue has been recognized by ACGME as requiring additional training within residency programs.
Giving physicians the knowledge, skills, and attitudes to address these needs has been the focus of an increasing number of articles and the development of a foundation of knowledge through scholarship. A survey of medical student pediatric clerkships across programs in both the United States and Canada (2) gives information about environmental characteristics, curricular content, and a strengths/weaknesses assessment. Benefits of ID/DD training that can generalize to overall medical training, including competence in chronic or long term care (as opposed to the acute care emphasis and prevention), agency exposure, and opportunities to understand perspectives of teachers and therapists and to hear stories of parents and their dealings with physicians, is discussed in another article (3). Benefits of ID/DD training for psychiatrists and skills that can generalize to other psychiatric patient care include multidisciplinary work skills, dealing with diagnostic complexity and multifactor etiologies, behavioral assessment, treatment and habilitation, and noncognitive aspects of psychotherapy, such as identification as an intervention are discussed in another set of articles (4–6), along with a set of psychiatry curricular recommendations (7). There are articles reviewing specific psychiatry residency rotation descriptions (8, 9) and a needs assessment survey of psychiatry residency program directors in the United States and Canada (10). There are articles within the pediatric literature where residents review a rotation and a survey of pediatric residents with regard to their attitudes and knowledge in intellectual disabilities (11, 12). Family medicine has examined this arena with an example of an article discussing a survey of residency program training directors (13). One survey of practicing physicians looks at their perception of knowledge and skills (11).
As we look to the future, we need to move beyond identifying needs to developing “best practice” models of educational intervention. One article begins to address this by discussing a collaborative program developed between an academic center and a county-based ID/DD agency (14). Collaboration with our colleagues in state and local agencies as well as advocacy groups will be important to share resources and support one another’s goals.
Identification of administrative solutions to obstacles in providing educational training is important, such as how to get ID/DD rotations the resident training program stipend support needed to ensure resident presence, how to get ID/DD rotations the faculty with clinical expertise to teach, how to help program directors to prioritize ID/DD training, and how to financially support faculty for teaching time. Finding ways to identify innovative educational interventions and how to distribute this information to other programs for replication is important as well.
In designing an educational curriculum, what is the best “vision” of a continuum of educational experience from medical school through residency training and into practicing physicians’ status with regard to knowledge, skills, and attitudes in the care of persons with ID/DD that will result in the best “physician product”? This was addressed in an initial effort by an APA work group that developed an “overview of mental retardation curriculum across levels of expertise” several years ago (15). With new educational monitors, what are the ID/DD educational criteria within the dimensions of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice that we should use as guides in our teaching for the different levels of medical student, resident, and practicing physician education?
In looking at the best instructional methods to use, are there electronic or online formats that can be shared across programs and institutions to aid in transmitting this body of knowledge and skills?
With regard to educational assessments, what are the educational measures of competence that we could use to measure progress, both in individual trainees and in educational program interventions, to achieve our ID/DD educational goals? Is there a role for standardized knowledge exams, standardized clinical exams (OSCE), or standardized patients?
In looking at clinical services, how can we better use measures of outcome improvement to begin to look at cost effectiveness of treatment as a way to advocate for patient care and training support?
We have a long history within medicine of physicians advocating for the care of persons with ID/DD and of thoughtfulness in how to educate medical students, residents, and practicing physicians in this body of knowledge, skills, and attitudes. As medicine and health care administration become more complex with more financial obstacles to care and treatment, it will be important that physicians have the knowledge, skills, and attitudes for future advocacy and care.
For the sake of those who are often unable to advocate for themselves, I hope we are up to the challenge.