THE NEXT STEP FOR INCLUSION:

STATE CME REQUIREMENTS ON DISABILITIES

BY ANNETTE SANJURJO LIZARDO, ESQ.

Living near several medical and dental facilities serving those with special needs, my middle, teenage son with nonverbal autism spectrum disorder (ASD), has received great medical and dental attention this last decade since he was diagnosed. Unfortunately, many others with cognitive, intellectual and developmental disabilities (IDDs) are not so fortunate.

Between 50-60 million people nationwide have a physical or mental impairment that affects one or more major life activities (such as making a meal, bathing, or doing errands alone), and approximately 5% of those people have a cognitive disability. (US Census, Pop. Est. rev. 2018). Undoubtedly, these individuals have even more difficulty accessing adequate medical care than others within the disability community. All medical practitioners serving patients throughout the lifes pan should be familiar with best practices for the delivery of healthcare to those with disabilities. A continuing medical education (CME) requirement on disabilities for all doctors (not just pediatricians) is long overdue.

In October 2018, The Health is for Everyone: Action Team (HEAT), led by the Association of University Centers on Disabilities (AUCD), helped sponsor Resolution 315 introduced by the American Academy of Pediatrics (AAP) on the "Inclusion of Developmental Disabilities Curriculum in Undergraduate, Graduate and Continuing Medical Education of Physicians" to the American Medical Association. The last clause of the resolution states, "RESOLVED, That our AMA encourage the Accreditation Council for Continuing Medical Education, specialty boards, and other continuing medical education providers to develop and implement continuing education programs that focus on the care and treatment of people with developmental disabilities." Thanks to the American Academy of Developmental Medicine and Dentistry (AADMD), these free CMEs already exist; however, there is no legal requirement for practicing physicians to take them.

STATE REGULATORY BOARDS NEED TO REQUIRE CME ON DISABILITIES AS PART OF RENEWAL LICENSURE

The American Dental Association (ADA) recently revised its code of conduct to prohibit denial of care to patients with physical, developmental or intellectual disabilities. "In cases where a dentist does not have the equipment or expertise to meet a particular person's special needs, the code now requires them to refer the patient to an appropriate dentist rather than simply turning them away."1 This is a start, but not the end. The ADA's code of conduct serves as the standard for state laws. The next step is for legislators to work with state regulatory boards and enact statutory amendments requiring CMEs on cognitive and IDDs.

Research universities receiving federal funds should be required to teach their medical students on physical, intellectual and developmental disabilities, and also provide clinical experience. While some universities have been reluctant to do so, others have proactively been at the forefront of serving the disability community. For example,

Since 1971, NYU College of Dentistry has run the successful Special Patient Care Program, an honors program for a small group of exceptional dental students to gain experience working with people with disabilities, but the center – the NYU Dentistry Oral Health Center for People with Disabilities, an 8,000-square-foot center renovated at the cost of $12 million located in the NYU College of Dentistry's Weissman Building, opened this February 2019, - now fulfills NYU Dean of the College of Dentistry Dr. Bertolami's vision of a dedicated dental home in New York City for individuals with physical, cognitive and developmental disabilities.2

Such initiative is commendable but should no longer be optional. All practitioners should be required to take CMEs on best practices to care and treat our disability community. Not only will these CMEs result in better short-term care and treatment, but also enable a smoother transition from pediatric care to adult and geriatric care. Should physicians continue to be unaware of best practices for treating patients with disabilities, thousands more will face misdiagnosis or missed diagnoses.

In the AMA December 2018 issue of the Journal of Ethics, Joel M. Reynolds, Ph.D., stated, "Clinicians wield enormous power over the care and treatment of people with disabil ities, a group every human will become part of over the life course… It is a power used unethically if clinicians do not actively learn about disability communities and practice disability humility."3 Reynolds observes:

Since the passage of the ADA [Americans with Disabilities Act] in 1990, people with disabilities make up the largest legally protected group in the country. In 2013, approximately 1 in every 5 adults reported a disability. Disability has always been and always will be a part of human life. Better care for the great diversity of people with disabilities – and, by extension, all peo ple – requires better engagement with and reflection upon the rich and complex meaning of disability. Insofar as the institution of medicine aims for just and equal care across individuals and groups, clinicians and members of society at large have a responsibility to educate themselves about disability and actively work against the effects of ableism that have too long undermined the justice and effectiveness of health care delivery. [citations omitted].

Rather than viewing those with different abilities as an inferior minority who burden society, embracing accommodations for the disability community benefits all of society.4

IF ONE BENEFITS, WE ALL BENEFIT

Disability awareness and accommodations benefit all of society.For instance, sloped sidewalks at intersections not only accommo date those in wheelchairs, but the elderly, parents with strollers, bicyclists and skaters also benefit. Similarly, handrails in public bathroom stalls not only assist the handicapped, but also mitigate liability by helping the elderly and small children when getting on/off the toilet.5 With physicians satisfying CMEs on disability awareness, medical practitioners will be able to welcome and provide more effective treatment for those with cognitive disabilities, just as their facilities have become more accessible to those with physical disabilities in the last few decades.

Three years ago, the April 2016 issue of the A continuing medical education requirement on disabilities for all doctors (not just pediatricians) is long overdue." AMA Journal of Ethics focused on key ethical concepts of the treatment of patients with intellectual disabilities. George Estreich wrote a personal narrative regarding his daughter and misperceptions about persons with disabilities. He commented on "the perception that Down syndrome is the 'good' special need, the appealing one, which seems unfair to kids with behavioral difficulties," and noted that, "People with Down syndrome now have a life expectancy of around 60 [citation omit ted]. If we think of them as permanent children, we will be less able to imagine a place for them in the world as adults."6 Estreich's comments on aging and behavioral challenges faced by some within the disability community are essential to the discussion on the future of healthcare delivery and disabilities.

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WELCOME CHANGE: Courses on disability awareness for physicians already exist and their mandated requirement will pave the way to improved healthcare delivery and access to all. This training should no longer be optional but a requisite part of continued licensure in Florida and nationwide to better serve our aging population with and without disabilities.

FLORIDA'S INCREASING NEED FOR CMES ON IDDS

FOR CMES ON IDDS According to the U.S. Census Bureau, as of 2017, over 13.5% of Florida residents had a disability. Retirees continue to flock to Florida, and some bring their adult children with disabilities. Although it is the fastest growing state in the nation, to date there is no mandated CME on disabilities for Florida physicians. It is paramount for Florida and other retiree-friendly states to implement best practices to successfully manage the increased number of patients with cognitive and intellectual disabilities who will be aging over the next few decades. All sub-specialists, not just pediatricians, should be cognizant of these best practices.

To date, Florida physicians are held to a lower standard of continuing education than teachers; unfortunately, this is the status quo across most of our nation. As per the Florida Board of Medicine, Florida physicians must satisfy 38 credit-hours of CME, including 2 credit-hours on Domestic Violence, 2 credit-hours on Medical Errors, and since Fall 2018, 2 credit-hours on Substance Abuse (due to the opioid crisis) every third bienni um. (See flboardofmedicine.gov/renewals/medical-doctor-unrestricted). A glaring omission is a minimum 2 credit-hour course on any type of disability. Meanwhile, teachers are required to take a professional development (PD) course on disabilities to better serve students who have either an undiagnosed disability or those diagnosed and included in general education ("typical") classrooms. Inclusion is intended to extend from the classroom to the workplace and community at large, including medical facilities. Tying ADA compliance with IDD training7 for continued receipt of federal funds is one way to benefit all patients.

Courses on disability awareness for physicians already exist and their mandated requirement will pave the way to improved healthcare delivery and access to all. As part of its FRIEND Residency Pilot Project, the American Academy of Developmental Medicine and Dentistry has a Physician Education in Developmental Disabilities (PEDD) webinar series with up to 12 credit hours for free sponsored by the U.S. Department of Health and Human Services, Administration on Developmental Disabilities and the Florida Developmental Disabilities Council, Inc., with additional support provided by the Florida Center for Inclusive Communities/UCEDD.8 (See aadmd.org/page/pedd-webinar- series). This training should no longer be optional but a requisite part of continued licensure in Florida and nationwide to better serve our aging population with and without disabilities.•

7. The U.S. Department of Justice, Civil Rights Division, has long focused its Barrier-Free Healthcare Initiative (2012) to enforcing the ADA in three main areas: (1) promoting effective communication through auxiliary aids to those who are deaf or suffer from hearing loss; (2) physical access to medical facilities for those with mobility disabilities; and (3) equal access to healthcare for those with HIV/AIDS. See ada.gov/usao-agreements.htm.

8. Each webinar is accredited by the American Academy of Family Physicians (AAFP). A similar webinar series also exists on their website that is accredited for nurses and nurse practitioners.

Special thanks to Stacey Hoaglund; Ann and Rud Turnbull, Esq.; Dr. Steve Perlman, Special Olympics Liaison, and Past-President of the AADMD; Dr. Rick Rader, Dir., Habilitation Center of Orange Grove Center, V.P. of Public Policy for the AADMD, Board Member of the American Association on Health and Disability, Emeritus Advisor to the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, and on the Special Olympics International, Global Medical Advisory Committee.

ABOUT THE AUTHOR:

Annette Sanjurjo Lizardo is mom to three lovely children, wife to Tony her husband of over twenty years, a lawyer, parent advocate, and graduate of Florida's Partners in Policymaking (FL '18) sponsored by the FDDC. Questions and comments may be sent to: lizardo.esq@gmail.com

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