Grover F. Powers, M.D., Contributing Editor
UNDERGRADUATE
TEACHING
OF
PEDIATRIC
REHABILITATION
By Abram Kanof, M.D.
Jcwish C/ironic Disease HO5/)ittIl and time Department of Pediatrics, State Unicersity of New York College of Medicine
From a report of the Comnmittee on the Handicapped Cilild, American Academy of Pediatrics, 1957.
ADDRESS: (Office) 90 Linden Boulevard, Brooklyn 26, New York.
EDUCATION
910
T
HE PEDIATRICIAN, ill his trachtiollalpre-occupation witil physical, psvchologic
educational and social problems, finds
him-self OD familiar grounds in tile “new”
p-cialtv of rehabilitation. The formal organi-zation of a specialty around! the collcepts of total care and teanl work does, however, impose upon ilinl the obligation to reassess
his understanding of this asl)ect of child
care, and to make certain he is utilizing all
tile principles and methods which are tile
products of specialized interest. For tile
teacher of pediatrics, this obligation is
especially urgent.
The present report deals witil the under-graduate teaciliilg of pediatric
rehabilita-tion. The study is based on voluntary re-plies to a questionnaire, sent omit by the Committee on the Haildicapped Child,
American Academy of Pediatrics. Seventy
answers to tile following questionnaire were
received from tile Deans of American nledi-cal schools:
QUE5TIONNA1E
I. Are onr students taught rehabilitation as
part of pediatrics: Yes, hours. No
2 1)o the vork iii a c-erel)ral pals\ clillic?
Yes,
-
- hours. No:3. Is there a cliyision or diepartlileilt of
rehabili-tatiOll at our school? Yes No
4. l)o your Sttldlellts receive instruction in:
a. Children’s orthopedics? Yes No
I). Childrell’s urology? Yes No
__
C. Children’s neurology? Yes No
ci. Psychology of handicapped children?
Yes
-
No_
(I. Sociologic prl)len1s of handicapped
dilil-dren? Yes No
-5. Please use the reverse side to commeilt Oil tile teaching of rehabilitation pediatrics.
ANALYSIS
OF
REPLIES
TO
QUESTIONNAIRE
The greatest difficulties in analyziIlg the data were tile variability of opinion as to
what rehabilitation is, and the diversity of
metilods by which tile specialty is fitted into hospital and medical school organization. The thinking as regards reilabilitation is often fragmentary, and there is still some antagonism to the idea of a separate
spe-ciaity. Some identify rehabilitation with psy-ciliatric care. Others discharge their
obli-gation to teacilmg of rehabilitation with a
visit to a custodial institution. Still others
believe that they have taught the subject if
tiley list the social agencies which exist for
the care and disposition of patients with
severe neuromuscular disabilities.
The case method of teaching makes it difficult to nleasure the number of hours
de-voted specifically to teaching rehabilitation. \Vhiie most of tile schools consider tilat tiley
do “teach reilabilitation, only a little more
tilan half answered the questions in a
man-11Cr Wilich indicated a specific plan for this
type of instruction during tile quarter
de-voted to pediatrics. Some of the Deans thought tilat rehabilitation should i)e taught
olliy in tile residency period, and tile
com-nlittee is now undertaking a studs’ of
teach-ing at tilat level.
Methods of Teaching
Of tile 70 Colleges of Medicine, 47 teach
EDUCATION
these may be divided into three groups. In the first group (17 colleges) there is a
de-partment of Physical Medicine and
Reha-bilitation (PMR) with a pediatrician at-tached to it. One gets the impression that
the best teaching in pediatric rehabilitation
is done in this group. However, only nine of
these have a specific number of ilOurs
as-signed for this teaching. The other eight
have the organization and the personnel, but teach rehabilitation on the basis of case work; students learn an approacil to
reha-bilitation i)y specific instruction at the bed-side, by assignment to orthopedic or neuro-logic or respirator wards, and by panel
dis-cussion.
In the second group (14 colleges) there is a department of PMR to which the pedi-atric students are assigned for a specified number of hours, but the teaching is not
done by a pediatrician. Many in this group stress interest in pediatric rehabilitation,
and some of them have great plans includ-ing new buildings or new wings, and special residents. In some, pediatric rehabilitation
is given only as an elective; in others an elective in reilabilitation may include up to
20 of pediatric cases. In some, members of the department of PMR participate regu-larly in combined clinics with the pecliatri-cians.
Tile third group (16 colleges) is somewhat
vague. Five answered question 1 \vitil a
“yes” but added nothing to substantiate this
answer. Eleven gave details which indicated
that rehabilitation was taught on a reason-ably good level, usually by affiliation with cerebral palsy clinics, mental retardation clinics or orthopedic hospitals. Some stressed the rehabilitation approach in con-nection with rheumatic ileart disease in clinics devoted to speech and hearing
proi)-lems, ill seizure clinics, and in
illterpreta-tion
oftue
normal developmental pattern. Twenty-tilree schools do not teachpedi-atric rehabilitation as such. These are so classified on tile basis of a flat “no” to the questions involved. Nine of these do not teach pediatric reilabihtation altilough they have a department of PMR.
Subject Matter
The subject matter of the instruction in-ciuded, in most instances, experience with
chronic illnesses of children, particularly
those with neuromuscular disabilities. In addition, there is a variable amount of em-phasis on the principles or philosophy of this field. We have selected tilree teaciling
pro-grams to illustrate both the uniformity and
diversity in teaching pediatric reilabilita-tion.
The first program, tilat of Cornell
Uni-versity Medical School, stresses the
psycho-logic and parental aspects. The program
fol-lows:
TEACHING PROGRAM IN PEDIArnic
RELIAmLI-TATION, PEDIA-riuc DEPARTMENT,
THE NEW YORK
HOSPITAL-CORNELL MEDICAL CENTER
Aims
I. Education
To teach medical students, house staff,
fellows and nurses the principles of
growth and development-physical as
well as psvchologic.
II. Service to Patients
Our thesis is that providing this kind
of basic knowledge and working with
the attitudes of the staff are as important
ill providing the best possible medical
treatment aild health supervision to
children of the community as is
informa-tiOll of a more technical nature that
traditionally makes up the content of the
Pediatric curriculum. III. Research (pending)
It is envisaged that as the program
de-yelops, there vill be opportunity for
investigative work in several areas, such
as personality development in children
vith physical disabilities,
psvchothera-Peultic techniques apphcal)le to
pedi-atric practice, and others.
Activities
I. Opportunity for learning growth and de-velopinent in normal cli ildren
a. \Vell i)al)y clinic aiid conferences.
1). New York Hospital Nursery School for
oi)servatioil of normal preschool
912
c. Clinics for health supervision of older
chilciren , including the adolescent
period.
II. Work wit/i sick 7)atietmtS to provide
con-tllluillg opportunities for the study of
psvchologic reactions to hospitalization,
illness and convalescence. Special
em-phasis OIl this aspect is provided by:
a. Psychiatric rounds on pediatric pavil-iOnS.
b. Vork in Division of Occupational and
Recreational Therapy.
c. Pediatric orthopedic rehabilitation con-ference.
d. Non-ortilopedic rehabilitation
confer-eilce.
ill. Parent discuss-ion groups-led by psycho-logically oriented pediatricians.
a. Group of mothers and ‘or fathers
dur-ing ante-partum period.
I). Groups of mothers of normal newborns
OIl pavilions.
C. Groups of pareilts of children with
chronic dlisease such as diabetes and
nephrosis.
d. Groups of parents of children attend-iug nurser’ school.
lv.
Prolongation of continuing doctor-patient relationship in order to make the experi-eice more rewarding for patient allddoe-tor and more instructive for doctor.
a. Comprehensive medical care and
teaching program enables medical
stu-dents to follow patients up to 6 months.
I). Follow-tip clinic enables house officers to follow patients for 1 to 2 ears in
hospital and outpatient department.
C. Postgraduate program gives fellows a
continuous 12 nlonths experience in
outpatient department.
ci. Clinics organized to provide individual appointments.
V. Arrangements to exten(1 plmys-iciaims
in-terest beyond the hospital and into the
home, scilool and community. a. Home-care program. i) Field trips.
c_ Case discussions and senlinars involy-ing community representatives.
(1. FallliiV-care )rogram.
VI. Emphasis on emotional and psijc-hologic
J;rol)lel;1s within the pediatric dlepartment. a. Psychological and emotional problems
are discussed ill relation to all sick and well children receiving their gen-eral pediatric care at Cornell University Medical Center, and are taken into account in planning their treatment.
b. Services of a psychiatric team are
available to permit more intensive study of selected patients.
c. This team assists members of the pe-diatric staff in their OWfl study and treatment of emotional problems. d. This team assists the pediatricians in
learning to determine which children
ileed referral to outside psychiatric
resources and teaches them how to
prepare the patient for such referral. VII. Pediatric lectures, seminars, case
discus-sions, clinical conferences are planned so as to include contributions from the psy-chologic disciplines whenever possible.
The program of Stanford Medical School
stresses the role of the physician in
rehabili-tation.
STANFORD MEDICAL SCHOOL
Rehabilitation Service Report to National Foundation for Infantile Paralysis in
Preparation for Conference on
Teaching of Rehabilitation February 14-16, 1956
Special Techniques of Rehabilitation Every
Medical Student Should Acquire
We agree with the view often expressed that rehabilitation is a philosophy, not a special
branch of the healing arts. We find it
impossi-ble to name a body of techniques which can l)e especially identified with rehabilitation.
Rather, rehabilitation calls for the application
of many techniques from various fields of mcdi. cine, social work, counseling, and others. The special technique required is that of integrating the contributions from these several fields. This
is ilot the reSpoilsibiiity of the physician alone, Ilor solely his prerogative. Therefore the prin-ci1)al thing vhicil the student must learn is
tile art of working with people skilled in other
disciplines, pooling his resources with theirs
for the good of the patient. Except for this,
the techniques used by the physician are those
a. Nursing 1). Social work
C. Vocational
counseling
d. Psychology e. Physical
ther-apv f. Occupational
therapy
g. Dietetics
h. Various
11011-medical
profes-Si0115 and
call-ings, e.g., school
teachers,
em-ploment
man-agers
state that he should have an excellent general
and medical education.
The technique of thinking with others can be
be specified ill more detail. It involves:
1. Acceptance of the leading role in
co-ordina-tiOl.
Medicine is the oldest and best established of the disciplines involved in rehabilitation. Its superior status carries with it the responsibility for assumption of leadership in health matters generally, and most particularly in matters per-taming to the health of an individual patient. The physician who fails to carry his patient
through to the most complete restoration of
function which can be achieved is not merely neglecting an important responsibility but often is preventing the accomplishment of this res-toration by other qualified workers.
2. Acceptance of essential equality of other disciplines.
a. Recognition that medical treatment is
ilot necessarily the most important factor in
the rehabilitation of an individual.
b. Recognition of the need for concurrent action by several disciplines.
Allied disciplines can motivate acceptance of prolonged or uncomfortable medical or phvsi-cal treatment. Concurrent action in different fields, within capacities of the patient to accept it, shortens the period of disability.
c. Readiness to permit a worker from an
allied discipline to develop a close personal relationship with the patient, even if this
dis-Pleases the transference which has been
de--eioped by the physician.
‘3.Appreciation of time conipetence of the allied
disciplines.
4. Appreciation of the limitations of medicine and of J)ersoflal limitations.
The student should develop such confidence
ill his O\Vil competence that it does not make
him uncomfortable to admit that workers in
allied fields are more able than he, in their
O\VIl areas of specialization. He should know that the other workers are not mere assistants
to whom a l)ortion of the medical function is
delegated, i)ut that the have, in their own
might, special skills which the physician is not
expected to d!isl)IUV. He should also know that
he caIlilot have the same competence for the care of all patients, recognize the kinds of pa-tients \vitil whom he is poorly adlal)ted, all(!
while still seeking to improve his adaptation,
be ready to relinquish such patieilts to another
phsician whose biases and interests are
differ-cut from ills OWU.
5. Techniques of interviewing and teaching
pa-tients.
The student should become adept at
obtain-ing information which is l)rOa(l in scope and
extensive ill detail without an excessive
cx-penditure of time. He should learn the
edu-catiollal principles which will serve him in
instructing patients effectiveh’ and in preparing
them for referral to other physicians and allied
workers.
6. Array of health and welfare services.
Students should learn the array of health
and welfare services which are ideally available in eveiv community, the extent of their devel-opment which he is likely to encounter ill van-ous places, the ways the\ can be used for the
assistance of his patients, and the role which
he may play in their development.
The tilird program, tilat conducted by the
author as a mandatory course for all pedi-atric students at State University of New York College of Medicine in New York City,
is presented as a practical example of a
12-hour introductory program. We offer in
adidlition, a 1-month elective in pediatric re-habilitation. The syllabus of the mandatory program follows:
J
EWISH CHRONIC DISEASE HOSPITALTeaching Schedule, Undergraduate Students,
1956-W57
The purpose of the sessions at the Jewisil Chronic Disease Hospital is to introduce you to the field of Pediatric Rehabilitation and to
iildlicate how the principles of rehabilitation
914
hope that this experience will perhaps
pro-vide a new perspective on the doctor-patient relatioiiship.
Part I: All-Day Clinical Session
in Small Groups
9:00-10:15 A.M.-Three patients will be
cx-amined on the ward: 1) a patient with recent
poliomvelitis tilus far treated chieflv b phsical
therapy; 2) a patieiit with poliomvelitis in
whom orthopedic procedures have been
per-formed!; 3) a Patient with spina bifida who will illustrate tile multiplicity of the problems
pre-sented IW a child with congenital anomalies.
Feel free to ask questions of the co-ordinator, or resident.
10:15-11:00-Review the three cases with
pedi-atric illstructor. Stress history and physical from
1)Oillt of view of fuilctioll and residuals. 1 1 :00-12:00-Rounds with pediatric co-ordi-nator. Demonstration anti discussion of uiltisUal
neurologic and musculoskeletal diseases.
12:00-1 :00 P.M-Lunch.
1 :00-4:00-Dr. Rogoff, in the Department of
Physical Medicine and Rehabilitation, will
dis-cuss the organization of his department, the
functions of its physicians and various
thera-pists (physical, corrective, occupational and speech), the use of the various modalities, and the philosophy of rehabilitation in general. The problems of the three specific patients assigned to the student will be discussed.
Emphasis is given to the fact that although
specific treatment to a diseased part is
neces-sary, frequently treatment consists essentially
of retraining the patient to use unaffected parts. Example : Training the patient with paralysis of one upper extremity to carry on his activi-ties of daily living with the remaining good arm rather than concentrating attention of patient and physician to treatment of the ineffective
extremity. In most neuromuscular disorders
treatment consists of maintailling the part in
as good functional position as possible and in
strengtheiling those parts having residual
func-tion. The over-all view of rehabilitation will be stressed; the necessity for considering tile
pa-tient as a whole and not as a “case.” The
child’s vocational and educational future will l)e coilsidered as part of the treatment. Mr. Chrystal, chief physical therapist, will demon-strate in detail the various methods of treat-merit, especially those being used for our
pa-tients. Clinical muscle testing will be explained
and demonstrated. Attend Department of PMR
evaluation collferellce.
4:00-5:00-Dr. A. Kanof on ward K5B. He will dlisduss ally questions arising during the day and also the nine principles of pediatric
re-hli)ilitatiOil, which can be enumerated! a
fol-lows:
I. Treat the Whole Child The child has a handicap The child has emOtiolls The child Illust play The child must learn The child has a family
The child must earn
II. Redefine Prognosis in Terms of What
Re-mains
III. Re-establish Function
IV. Rehabilitation is a Long-Range Process V. Rehabilitation Demands Teamwork
VI. Teachability is the Cornerstone of
Re-habilitation
VII. Parents Are oii the Team
VIII. There is a Prophylactic Aspect to
Re-habilitation
Ix.
Growth aild Development AffectRe-habilitation
Part II: Teaching Evaluation Conference
This 4-hour session is an actual evaluation
conference built around two patients with a
great variety of physical, pschologic and
soci-ologic problems. The entire medical aIld
para-medical team attends, and conducts itself as it
would at a regular evaluation conference
cx-cept that they are also called upon to briefly summarize their general function in rehabili-tatioll. The students are given case summaries
ill advance so that they may be called upon to
participate actively.
SUMMARY
More than half of American medical
schools teach rehabilitation as part of tile
pediatric curriculum.
There is great variability in the quality and quantity of such teaching.
Three typical syllabuses are reproduced: One stresses the psychologic and parental
