Area 2: Educational programme

This area made up the bulk of the indicators and was divided into two sections: a) methods and activities and b) content. The WFME had eight standards in this area. The first six standards covered educational principles and were incorporated in area 2a. The seventh standard (programme management) was covered in this study in the area of governance and administration (area 8 below). The eighth standard called for linkage with medical practice and the health system and this was expanded in 2a to cover overarching principles such as team work and the role of the GP in managing persons with disabilities. Area 2b was created to further expand on the eighth standard to cover the content of clinical rehabilitation practice in SA.

3.3.2.1 Area 2a: Educational programme: methods and activities

Area 2a referred to educational methods or activities that were considered internationally appropriate (such as lectures, patient contacts, case discussions, contact with community resources, simulation of a disability, exposure to teamwork, teaching by doctors, therapists and patients, reflection on learning activities) to achieve the rehabilitation programme objectives and competencies. These are listed as indicators 2.1 – 2.20. Methods such as team work and teaching by patients were considered mandatory for a rehabilitation training programme. The listing of these indicators follows the ordering of the WFME standards rather than the literature review.

 2.1 A variety of educational methods or activities as listed above should be used. To gain insight over and above the literature, enquiry into additional methods and activities that could be considered as well as those preferred was included with this indicator. The full list used in this study included: Lectures by rehabilitation clinicians, lectures/discussions with persons with disabilities to understand the impact of disability, evaluating patients with disabilities, case discussions, exposure to teamwork, home visits, group research/projects, presentation to class/group, visits to community rehabilitation resources, practical demonstration of patient evaluation and examination,

practical demonstration of skills (e.g. stump bandaging, wheelchair positioning, patient transfers), simulation of a disability (e.g. spending a day in a wheelchair or on crutches), reflection on learning experience.

 2.2 Apart from identifying the methods and activities to be used, the students need to be prepared that they may learn in a way not previously experienced e.g. from the members of the inter or multidisciplinary team. They may be exposed to situations that may invoke emotions or reactions. For example students need to be prepared to deal with the challenges of applying a conventional approach to assessing and managing persons with disabilities and alternatives need to be discussed before the students complete their activities.

 2.3 The study guides need to be written and presented in a format that makes the contents readable and clear. They must contain all the relevant information (objectives, competencies, educational methods or activities, sequencing of activities, assessment methods).

 2.4 The activities should be sequenced so that students are first exposed to attitudinal and general principles in disability and rehabilitation before being taught specific knowledge and skills in order to manage a person with a disability. Concerns that the current sequencing of the activities in the middle and theory blocks may impact on the students’ results were included, and this was investigated using methods suggested under area 7.

 2.5 Community based education was considered to be a modern educational principle

and primary health care a core component of health delivery systems. Students thus should be placed in clinical community rehabilitation settings for Rehabilitation programme activities.

 2.6 Clinical placements should support and not burden the community rehabilitation resources. Resources included the facilities, staff, patients and their carers.

 2.7 Mandatory to the Rehabilitation programme should be the exposure to inter or multi-disciplinary team work. It was preferred that exposure to team members should occur in the rest of the curriculum as well.

 2.8 It was mandatory that students observe doctors functioning within inter or multi- disciplinary teams during the Rehabilitation programme. It was preferred if this occurred during other programmes in the curriculum.

 2.9 The Rehabilitation programme should provide an opportunity for students to acknowledge and explore attitudes towards teamwork. A question raised in the

literature review was the value that students place on teaching by members of inter or multidisciplinary rehabilitation teams. This was explored under this indicator.

 2.10 Inter personal communication was a general education principle but critical to rehabilitation practice so should be addressed during the activities of the Rehabilitation programme.

 2.11 It should be mandatory that medical students have an opportunity to socialise with other disciplines formally during educational activities. It was preferable that they also socialise informally e.g. on campus or in their private time.

 2.12 Students are trained for their future role in primary health care so they should identify with, through observation, the role that GPs have in managing persons with disabilities in the community. The literature posed conflicting perceptions of patients and GPs as to the roles and functions of the doctor in the community. This was investigated together with this indicator.

 2.13 Students should be taught to manage persons with disabilities as they move through all levels of the continuum of health care i.e. in primary, secondary and tertiary care, in acute, post acute and chronic care, in the public and private sector, in specialised ambulatory (community) and residential (in-patient) rehabilitation settings.

 2.14 Reasons were given in the literature review why doctors may have poor attitudes

to persons with disabilities Students thus need to be given an opportunity to reflect on these personal attitudes. The researcher was also curious to know the direction of this attitude so the value that students place on teaching by persons with disability was also evaluated. Although contact opportunities are provided with persons with disabilities in the programme, students exposure otherwise was explored as this was reported to effect attitudes.

 2.15 Horizontal integration of teaching across a curriculum was considered a modern educational principle. As this may be beyond the control of the Rehabilitation programme the application of rehabilitation knowledge to other medical specialities during the curriculum was preferable. As much of the literature was internationally based where PM&R is a registered speciality and there was limited reference to integration of rehabilitation training across curricula, preferences regarding integration was further evaluated in this study.

 2.16 Management of persons with disabilities calls on a wide range of knowledge and

skills which cannot all be delivered within the confines of a Rehabilitation programme or covered to the extent that can be within other speciality programmes. Students are thus

required to apply knowledge, skills and attitudes acquired in other medical specialities to manage persons with disabilities in the Rehabilitation programme.

 2.17 Evidence based practice, problem solving, critical thinking and clinical reasoning should be used to make students responsible for their own learning.

 2.18 To facilitate vertical integration of a curriculum the programme should require students to draw on learning in basic medical sciences in order to manage persons with disabilities.

 2.19 A certain degree of repetition is required within a programme or curriculum to reinforce learning however there should not be unnecessary repetition of content within either.

 2.20 Electives in rehabilitation should be offered but as these are dependent on clinical resources and beyond the control of the department organising the programme, this was preferable.

3.3.2.2 Area 2b: Educational programme: content

The content of the Rehabilitation programme should be relevant to the clinical environment in which the medical graduates will practice, which in SA is the primary health care setting. These indicators are listed as 2.21 – 2.25.

 2.21 Literature on disability and rehabilitation was found to frequently refer to the ICF which provides a meaningful picture of health. As discussed in the literature review it provides a framework against which the definition of disability and rehabilitation should be taught.

 2.22 A list of health conditions based on SA and international literature was compiled. It was expected that students should be taught the rehabilitative management of these conditions. This list was however based on specialised rehabilitation services due to limited data from generalist and community sources. The completeness and appropriateness of this list in the local health context (WC, SA) was explored against this indicator in this study. The full list used in this study was; stroke, head injury, spinal cord injury, TB related neurology, HIV related neurology, psychiatric conditions, amputation (traumatic or vascular), visual impairment (irrespective of cause), intellectual impairment, cerebral palsy, poly-trauma.

 2.23 A list of bio, psycho and social needs of persons with disabilities based on the literature and the researcher’s experience was compiled. It was expected that these be addressed in the programme. Again this list was verified as to completeness and appropriateness. The full list used in this study was: medical management of the

condition (re-boarding of medication, medical stabilisation), pressure sores, pain management, circulation problems and deep vein thrombosis, bladder problems, bowel problems, sexual dysfunction, needing dietary advice, needing assistance with self care, needing assistance with mobility or requesting assistive devices (issue or repair), needing advice regarding return to school or work, feeding and swallowing problems, visual problems, communication problems and speech difficulties, cognitive and perceptual problems, interpersonal relationship issues, coming to terms with being disabled, patient and carer education, needing help with transport or getting to work/shops/church/etc, application for financial benefits (disability or insurance claims), patient and carer support .

 2.24 The various models of care (e.g. medical, social and bio psychosocial models) highlighted the need for students to be taught how to manage the needs of persons with disabilities through medical and trans-disciplinary management, inter or multidisciplinary referral and use of community resources. The details of each of these management approaches were further explored along with this indicator.

 2.25 Students should be taught a generic approach to disability management so that they can manage any health condition causing disability.