People with disabilities often miss prevention, wellness care

Washington -- A new federal report is calling attention to the fact that people with disabilities can lead long and healthy lives, but too often they fall through the cracks when it comes to the health screening tools given to more able-bodied people. Part of this message is aimed at primary care physicians who might not be seeing -- in these cases -- the entire patient.

People with disabilities are still not getting the health care that is available to others, said U.S. Surgeon General Richard H. Carmona, MD, MPH, in a document intended to change this situation. "Today, we must double our efforts so that people with disabilities achieve full access to disease prevention and health promotion services," said Dr. Carmona, who issued a July 26 "Call to Action to Improve the Health and Wellness of Persons with Disabilities" to mark the 15th anniversary of the passage of the Americans with Disabilities Act.

About 54 million Americans -- one in five -- are living with at least one disability, and most Americans will experience a disability at some point, according to Dept. of Health and Human Services figures. Physicians have a responsibility to ensure that the health care of this population is inclusive, Dr. Carmona said. He encouraged doctors to treat the whole person, not just the disability.

"We must learn to recognize the abilities of persons with disabilities," said Margaret Giannini, MD, director of the HHS Office on Disability. "People with disabilities can learn, get married, have a family, worship, vote, work and live long productive lives," she added. "We need to make sure we treat them as active members of our society."

Peter A. Galpin, MD, a surgeon in independent practice on the Hawaiian island of Maui, noted that many people with disabilities already function in this manner. Dr. Galpin performs operations from his wheelchair, having been paralyzed in 1977 when he was hit by a drunk driver.

"With the right equipment and training, I was able to move around the operating room without contaminating the space and do everything that other surgeons do on two legs," Dr. Galpin said at the announcement of the call to action.

Lisa I. Iezzoni, MD, MSc, professor of medicine at Harvard Medical School and a researcher on health care issues for people with disabilities, also uses a wheelchair. "We clearly hear reports from people with disabilities that their physicians aren't thinking of them as a whole person but are focusing on the specific underlying condition that causes their disability."

Although the patient's underlying condition might be a proper focus for an office visit, "physicians need to also think about every other issue they think about for everyone else," she added. "People still have a life, and they want to live that life as long and as healthy as they possibly can."

What works

People with disabilities might need to be encouraged to lose weight, get a mammogram or a prostate exam, said Jaye Hefner, MD, MPH, instructor in medicine at Harvard Medical School. Encouraging them to get screening tests sends the message, "When you are 70 or 80, you'll be in the best health you can be."

Physicians may be able to work with a patient's insurance company to gain coverage for extra physical therapy sessions that could include a program of home exercises, Dr. Hefner suggested. Or a patient can be sent to a nutritionist.

Treating secondary conditions is also important, she added. People who propel themselves in wheelchairs can develop shoulder problems. Depression and substance abuse also can be triggered by a disabling condition.

Although the need for treating people with disabilities is apparent, it can pose challenges to physicians. An office visit might consume more time than insurance companies are willing to cover, several experts noted. Just getting a person into the office and on an examining table might take longer than the 15 minutes allotted. And paying for a translator when treating a person with a hearing impairment can mean incurring another unreimbursable expense.

But training office staff to help transfer a patient with a mobility disorder to an examining table quickly and safely might be a low-cost option for care. Purchasing a $50 sliding board also could improve access, Dr. Hefner said.

Another treatment obstacle is physicians' lack of training in treating patients with disabilities. "I think it is just getting to the point now where doctors are thinking that people who have a disability or chronic disease can still be well," she added.

That knowledge can spread as a result of the surgeon general's directive.

Drs. Hefner and Iezzoni also are participating in a Sept. 17 Harvard symposium, "Providing Quality Care to Women with Visual, Hearing and Mobility Impairments." Sessions are scheduled on patient-clinician communication and appropriate exams.

Key to connecting patients and physicians is the physician's level of comfort in treating a person with a disability, said Margaret Turk, MD, professor of physical medicine and rehabilitation at the State University of New York Upstate Medical Center in Syracuse. Dr. Turk also will be participating in the Harvard symposium.

That comfort is acquired through training and first-hand experience, she said. "The prevalence of disability in America is significant enough and varied enough that it is important that there be some periodic focus on people with a variety of disabilities and that it be acknowledged in training programs."