Kristi L. Kirschner

Construct and Predictive Validity of the Repeatable Battery for the Assessment of Neuropsychological Status in the Evaluation of Stroke Patients

To evaluate the construct and predictive validity of a brief neuropsychological assessment battery, consecutive admissions to a hospital receiving inpatient treatment for stroke were tested with the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) and other neuropsychological measures. Discriminant and convergent validity were adequate for the Language, Visuospatial/Constructional, Immediate Memory and Delayed Memory indices in the RBANS, but weaker for the Attention Index. Twelve months later, 36 discharged patients were contacted by telephone and interviewed using a battery of functional outcome measures. RBANS Total Score predicted cognitive disability as measured by the Functional Independence Measure. Individual indices from the RBANS also predicted instrumental activities of daily living (IADLs) as measured by the Frenchay Activity Index and participation restrictions as measured by the Craig Handicap Assessment and Reporting Technique. The present findings suggest that the RBANS can be a useful tool in the neuropsychological evaluation of inpatients with stroke. Thanks to Brooke Donnelley, Jeremy Clorfene and Michael Ostrom for their extensive assistance in this project. Thanks also to Christopher Randolph for his assistance with this manuscript. Supported by the US Department of Education, National Institute on Disability and Rehabilitation Research, grant H133B30024 through the Rehabilitation Research and Training Center on Enhancing Quality of Life of Stroke Survivors

Brief cognitive assessment and prediction of functional outcome in stroke.

Abstract To evaluate the ability to predict outcome with a brief measure of cognitive ability, we tested consecutive admissions who received inpatient rehabilitation for stroke with the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS). Six months later, 34 discharged patients were contacted by telephone and were interviewed using a battery of functional outcome and quality of life measures. Multiple regression analysis showed that inpatient RBANS indexes predicted cognitive disability 6 months later. The present findings support the use of cognitive evaluations of patients with acute stroke to assist with prediction of outcome to be used in treatment planning.

Educating health care professionals to care for patients with disabilities.

THE US SURGEON GENERAL’S CALL TO ACTION TO IMprove the Health and Wellness of Persons With Disabilities was released in 2005 on the 15th anniversary of the Americans With Disabilities Act. The report noted increasing evidence that individuals with disabilities have worse health status than those without disabilities and that resources for persons with disabilities to maintain health, prevent secondary conditions, and optimize wellness are inadequate. The failure of medical education programs to teach concepts of disability was identified as a root cause, and educators were encouraged to “increase knowledge among health care professionals and provide them with tools to screen, diagnose, and treat the whole person with a disability with dignity.” Professional education about disability is a critical element in achieving quality health care, and having core competencies for health care professions education about patients with disabilities may help to achieve these goals. The reality that disability is a universal aspect of human experience, affecting nearly everyone at some point in his or her life span, is critical to the development of these core competencies. Following this principle of universality, disabilityrelated learning objectives should be integrated, insofar as is possible, into existing standards, competencies, and curricular formats. New and distinct curricular components should then address any critical gaps. This approach resonates with the perspective of many health care professions educators involved in disability issues: it holds a direct analogy to the principles of “universal design” in the physical environment, which encourages “the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design.” For every existing core competency in medical school and residency curricula (eg, interpersonal and communication skills, systems-based practice), health care professions educators should first ensure that the learning objectives for this core competency address the issues and needs of the broadest population. The second task then becomes identifying additional concepts and principles of care that are specific to disability and caring for persons with disabilities. Consider, through this lens, a curriculum in patientclinician communication. Its general principles, such as maintenance of eye contact when communicating, have implications for the care of patients with disabilities that should be made explicit. These would include, for example, sitting down to speak eye-to-eye with a wheelchair user or talking directly to a hearing-impaired person, rather than to that person’s sign language interpreter. Beyond these basics, this curriculum also should include skills specific to communicating effectively with persons with speech or language impairments, intellectual disabilities, and physical or sensory disabilities (such as the use of pictorial boards, assistive communications technologies, Braille or large print, and TTY machines or telephone relay operators).

Successful pregnancy in a patient with spinal muscular atrophy and severe kyphoscoliosis.

Pregnancy imposes a load on the respiratory system that is usually easily assumed because of alterations in the thoracoabdominal architecture. It is presumed that the respiratory mechanical disadvantage of severe kyphoscoliosis and the muscle weakness of spinal muscular atrophy impede these adaptations sufficiently to preclude a successful gestation. We report the case of a successful pregnancy in a woman with spinal muscular atrophy, severe uncorrected scoliosis, and the lowest spirometric values reported in the literature without the use of ventilatory support. This patient demonstrates that women with severe kyphoscoliosis and a profound ventilatory limitation can carry a successful pregnancy well into the third trimester without requiring full ventilatory support.

Pregnancy Outcomes of Women With Physical Disabilities: A Matched Cohort Study

To document pregnancy outcomes of women with moderate‐to‐severe physical disabilities and to evaluate maternal and fetal outcomes compared with those of nondisabled 1:1 matched controls within the same hospital system.

North American medical schools' experience with and approaches to the needs of students with physical and sensory disabilities.

Purpose To determine the nature and frequency of impairments and related underlying conditions of medical students with physical and sensory disabilities (PSDs), and to assess medical schools’ use of relevant publications in setting admission criteria and developing appropriate accommodations. Method A 25-item survey addressed schools’ experiences with students known to have PSDs and their related policies and practices. The survey instrument was directed to student affairs deans at all 163 accredited American and Canadian medical schools. The authors limited the survey to consideration of PSDs, excluding psychiatric, cognitive, and learning disabilities. Results Eighty-six schools (52.8%) responded, representing an estimated 83,327 students enrolled between 2001 and 2010. Of these students, 0.56% had PSDs at matriculation and 0.42% at graduation. Although 81% of respondents were familiar with published guidelines for technical standards, 71% used locally derived institutional guidelines for the admission of disabled applicants. The most commonly reported accommodations for students with PSDs included extra time to complete tasks/exams (n = 62), ramps, lifts, or accessible entrances (n = 43), and dictated/audio-recorded lectures (n = 40). All responding schools required students’ demonstration of physical examination skills; requirements for other technical skills, with or without accommodations, varied considerably. Conclusions The matriculation and graduation rates of medical students with PSDs remain low. The most frequent accommodations reported were among those required of any academic or clinical setting by the Americans with Disabilities Act. There is a lack of consensus regarding technical standards for admission, suggesting a need to reexamine this critical issue.

Technical standards for the education of physicians with physical disabilities: perspectives of medical students, residents, and attending physicians.

VanMatre RM, Nampiaparampil DE, Curry RH, Kirschner KL: Technical standards for the education of physicians with physical disabilities: Perspectives of medical students, residents, and attending physicians. Am J Phys Med Rehabil 2004;83:54–60. ObjectiveThis pilot study assessed the opinions of medical students, residents, and attending physicians regarding the technical standards for medical school admission and the competencies required of graduates in the context of physical disability issues. DesignStudents, residents, and faculty from all specialties at a major academic medical center were surveyed regarding the concept of the “undifferentiated graduate;” the relative importance of motor, sensory, observation, and communication skills; the importance of specific technical skills; and the use of physician extenders and other accommodations to fulfill technical standards. ResultsRespondents placed higher importance on observation and communication skills compared with motor skills. Of respondents, 69.8% either disagree or strongly disagree with the idea that a medical student should be an undifferentiated candidate possessing all the technical skills necessary to enter any specialty. ConclusionsTechnical skills used in interpretation and observation were more important to respondents than those technical skills that are purely procedural. Respondents largely rejected the concept of the undifferentiated graduate. Although statistical analyses are of limited reliability because of low response rates, this study represents the most extensive sampling to date of medical professionals’ opinions on these issues. Respondents’ narrative comments also provided valuable perspectives.

Moral Distress in Rehabilitation Professionals: Results From a Hospital Ethics Survey

Moral distress in the rehabilitation setting was examined in a follow‐up survey. The survey had 3 goals: (1) to systematically and anonymously gather data about the ethical issues that employees struggle with in their daily work; (2) to raise the visibility of the hospital‐based ethics program and resources available to employees; and (3) to prioritize and focus the direction of the programs educational seminars, quality improvement projects, and ethics consultation.

Recombinant Human Erythropoietin: Effect on the Functional Performance of Anemic Orthopedic Patients

OBJECTIVE To determine whether rapid correction of anemia improves the functional and cognitive performance of postoperative orthopedic patients. DESIGN A randomized, double-blind, placebo-controlled clinical trial. SETTING A rehabilitation institute. PATIENTS Persons having orthopedic surgery at least 2 weeks previously, and a hemoglobin concentration < 10g/dL. INTERVENTIONS Recombinant human erythropoietin (rH-EPO) or the EPO vehicle for up to 8 weeks. All patients received ferrous sulfate. MEASUREMENTS Blood counts were performed at weekly intervals, and functional and cognitive tests at baseline and weeks 4 and 8. RESULTS In patients receiving vehicle only, hemoglobin levels increased from a mean of 9.0 at baseline to 11.0 at 4 weeks and 11.7 at 8 weeks; corresponding values for rH-EPO were 8.8 (p = NS), 12.6 (p = .02), and 13.5 (p = .01). However, functional improvement in dressing, toileting, and mobility was similar between groups, and the results of neuropsychological tests showed no trends favoring rH-EPO. CONCLUSIONS Although hemoglobin increases more rapidly in anemic orthopedic patients treated with rH-EPO, equally rapid functional improvement occurs in those who receive only iron therapy.

Abandoning the Golden Rule: The Problem with “Putting Ourselves in the Patient’s Place”

Abstract A large body of evidence documents the difficulties health care professionals have in predicting their patient’s beliefs or wishes. These difficulties extend from the predictions of very specific patient wishes (such as for life-sustaining therapies) to more global assessments of patients’ lives as a whole (for instance, their quality of life). Although many explanations have been offered for this phenomenon, we discuss one that has not received as much attention: the conscious or unconscious adoption of what we refer to as Golden Rule thinking. This refers to our attempts to understand another person’s situation by imagining what we would believe or want under similar circumstances, in other words, “putting ourselves in the patient’s place.” Although Golden Rule thinking would seem to be a promising strategy, studies show that it actually results in inaccurate predictions of patients’ wishes or beliefs. These mispredictions, in turn, have significant clinical and ethical implications. We review possible reasons why Golden Rule thinking may be of limited utility in understanding our patients’ situations and suggest alternate strategies to maximize our understanding of our patient’s lives.