administrative concerns and schools' relationship with private practicing physicians

Administrative Concerns and Schools’ Relationship With Private Practicing Physicians

Elizabeth Bryan, MD

INTRODUCTION For many years, physicians were seen as enhancing

the school life of children by keeping them healthy enough to have regular attendance and to feel well enough to participate in the educational program. Thus the physician was perceived as an inoculator and a treater of illnesses and injuries. In the past several years, increased knowledge has shown the learning process to be quite complex; the training and practice of physicians have changed and include an interest in total growth and development; and more severely handicapped and younger handicapped children have become the responsibility of schools. With these changes has come a realization by some school administrators that physicians can make additional contributions to the school welfare of children. Dealing with a disciplinary group (physicians) that practices outside the school setting, has its own system of beliefs and ethics, works with a selected clientele but has a deep interest in patients served, has led to development of a number of problems for a school administrator.

Four administrative concerns regarding schools’ relationship to practicing physicians which are ad- dressed here are that (1) all medical information be obtained which is necessary or useful in planning a safe, productive school program for each child, (2) the medical information be used to best advantage for that child, (3) a working, mutually supportive relationship be maintained between the physicians of the community and the school, and (4) the cost of obtaining needed and/or desired medical information be kept within the assigned budget. Suggestions will be made for dealing with each concern in the discussion.

OBTAINING INFORMATION The first administrative concern is to secure medical

information needed and/or useful to make safety arrangements, to plan productive educational programs and to meet certain legal requirements.

In order to supply useful, interpreted medical information, practicing physicians must know of school program possibilities, liabilities and limitations. The school should help the physicians understand what these elements are for the total program and for specific children and situations. Activities designed with this purpose should be built into the school programs as an assigned responsibility of a member of the district staff. The efforts must be continuing, varied and deal with material relevant to physicians’ interests.

School staff must continuously be alert to recognize when a change in the program might have an influence on the attitude or performance of physicians. A list of physicians who provide medical supervision to most of the children in a program can be maintained. Periodically, communication can be made with these physicians. For instance, recently Edmonds’ nursing staff was cut to one third of its former size. A letter was sent explaining that the helpful communication system to which the physicians were accustomed had to be dis- continued, and they were asked to assume more direct responsibility for supplying needed information to the schools about their patients.

Other general communications from Special Educa- tion Services have been mailed. These have included requests for specific help from the practicing group, explanations of the medical implications of laws which govern schools, and notification of changes in laws and

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procedures which might affect the physicians’ activities. Notices of area or state meetings sponsored by educational organizations, often with significant medical content, are posted on the local hospital bulletin board.

When information is needed for specific situations, first determine exactly what is needed at school level and for what purpose. For instance, in Washington State, a certain portion of the state funds are allocated on the basis of numbers of children in different diagnostic categories. A direct statement from a physician is required in some categories. This is important from the standpoint of planning a program for an individual child because operating funds are involved. A form describing this situation lists criteria given by law for different diagnostic categories and requests the physician to fill it in appropriately has elicited helpful responses.

The most helpful forms for school-to-physician communications about individual children have been those that provide an adequate account of observations of the child while at school, reason for requesting information, and specific questions requiring answers. Efforts to develop a number of forms for specific use have been worthwhile. For example, a medical clearance report is required for students with a hearing impairment when swimming is planned in physical education. Program dates, permission to participate, and necessary precautions are included in this form.

These types of communications help the practicing physician to know more about the school programs, to develop respect and understanding for the supervision provided at school for their child patients and also lead to some familiarity with names and functions of school personnel.

For school staff to obtain useful, interpreted medical contribution requires that they be aware of what a physician can be expected to provide and some understanding of ethics, procedures and limitations of medical practice. Activities designed to assist in the development of the above understanding should be an assigned responsibility of a member of the district staff. These efforts must be ongoing, varied and deal with issues relevant to the interests of the teachers and others working with the students. The responsible school staff member must be continuously alert to concerns which have aspects involving medical knowledge, practice or procedure. Some of these concerns are handled best on an individual basis, some by planned meetings or in-service; but there must be a district mechanism and personnel to respond. Some problems are easily resolved. Typical is that of a teacher who feels rejected when unable to talk with a physician by phone in midafternoon during office hours. When the physician returns the call during a time alloted to answer

158 THE JOURNAL OF SCHOOL HEALTH

messages, the teacher is unavailable. Usually an explanation to the teacher about this procedure will lead to satisfactory adjustments on both sides to resolve the problem.

Other situations are more complicated. An example: cognizance that some school staff were referring students to favorite practitioners and clinics regardless of the former source of the student’s medical care. This concern caused the district administrator to appoint a committee composed of representatives from administration, psychological services, nursing services, communication disorder specialists, teachers, counselors and chaired by the school physician. This committee’s charge was to develop a district policy and procedure for “Referral to Outside Agencies and Individuals.” This committee deliberated over a two-year period. The result was a statement of policy and an outline of procedure that was accepted and approved by administration and the school board. It is now a part of the district policy handbook. It is a useful document, outlining a procedure that aids in obtaining helpful, pertinent material. It maintains parents’ prerogatives for choosing their own source of care. It exercises the courtesy due an individual outside the school system who has been involved with the family concerning the problem presented at school. This document is distributed and used as a basis for discussions in both individual and group in-service and orientation.

In regard to individual children, school staffs need help to gain an understanding about the handicapping conditions that the children have and the educational implications, including necessary safety precautions. This should be done on an individual basis regarding specific children. Also helpful are planned sessions about disease entities or treatment methods. Requests for these types of in-service often come from school personnel. Response should come from an individual who has an added responsibility of supplying current knowledge about latest authentic medical information available from experts in medical fields. Planned sessions conducted by a recognized medical expert and reports of meetings at which appropriate topics are discussed should be offered to help increase awareness of when to ask specific questions about an individual child. Also, notification should be given of appropriate continuing medical education offerings to which educators are eligible.

Teachers should be involved in the development of each form to be used to communicate with the physician. Usually the teacher is the logical starting point. For instance, the first step in the development of a form to be completed by the eye specialist for visually handicapped students was to ask the teacher what information was necessary to plan the school program. Items needed to supervise safety and to meet legal

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requirements were added to complete the form. This activity led to obtaining useful information from medical resources and to alerting the teacher to possible contributions from the physicians.

If, then, there is a group of physicians in the community outside the school aware of school programs and of their contribution to these programs and a staff within the school who is appreciative of medical contribution and methods provided with which they can communicate, it becomes possible to deal with the first administrative concern of obtaining needed medical information for safety of students and staff, for program planning and to meet legal requirements.

USING INFORMATION Seeing that the available medical information is used

to the child’s best interest is a second administrative concern. Practicing physicians are interested that their efforts to communicate benefit the children. In fact, the medical alert system developed in Edmonds was stimulated by the question from physicians and special education parents, “How do we know the information we send to you is used routinely at school?”

The medical component and its implications should be included by plan and recorded routinely at each stage of evaluation and program planning. It is not enough to assume that if no mention is made, there is nothing of medical significance or that pertinent medical situations will be entered under a category such as “Other.”

In reviewing medical information, an important fact is whether a student has some condition which puts him/her in a highly hazardous situation and in almost constant danger of a medical emergency. To manage these children adequately, they must be easily identified by all staff dealing with them. Procedures for management in case of an emergency must be prepared. Responsibility for action must be assigned to an appropriate staff member.

A second group of children who are of concern are those for whom no emergency is expected but who require careful, knowledgeable supervision at school. This includes children with diabetes, asthma, controlled convulsive disorder, and severe allergy to bee stings. Before the child attends school, the staff is alerted to the presence of the child’s condition and informed of observations which should be made and procedures to follow.

A third group of children for whom special arrangements are made before they enter classes are those who have some restrictions of activity due to a medical condition. These restrictions are written by the child’s medical practitioner and known to the staff. School programs are modified in accordance with these recommendations.

One way of managing these situations is a medical

alert system which requires that each student in the above three groups have a medical alert sheet prepared for them. This bears the child’s name, placement, reason for concern, recommended management and name of a support staff member who is the resource for the teacher and is responsible for reviewing the situation on a planned basis. This alert sheet is on bright paper and filed in a prominent designated place in the child’s record. Copies are distributed to appropriate individuals, including the principal and manager of the child’s special education program.

In order to easily identify the urgency of each child’s medical situation, each student receiving special education services in Edmonds is given a medical priority number. Explanations for 1,2 and 3 priority are given above. Medical priority 4 is for children not included in 1, 2, or 3, but who require careful observation of hidher performance and behavior and must have periodic written reports sent to the student’s physician because of medical condition, interest or requests from the physician.

Medical priority 5 includes children not known to be eligible for any of the first four categories for whom current medical evaluation needs to be included before assessment is considered complete. This group is composed of students for whom school observations, history in school records, items in reports of school personnel (teacher, nurse, psychologist, caseworker, communication disorder specialist) indicate a reason- able possibility of a medical component to the student’s difficulty, but there is no medical report, the medical report is outdated, or the report indicates that the physician had insufficient knowledge of the student’s school performance when the evaluation was done.

Medical priorities 6, 7, 8, 9 range down to lesser degrees of concern about the medical component until 0 is reached. Zero classification signifies that a student has been evaluated recently by his physician, that the physician had school reports available at evaluation and that there was no indication of medical difficulty reported. Also, school observations and records indicate there is no likelihood of presence of medical condition.

Ability to use this medical priority system has been built on previous preparation of other procedures and trainings. Prepared with help from practicing physicians, a teacher checklist is an important tool used to record observations which, if present, indicate a reason- able possibility exists that a medical component to the problem is present. Then a medical evaluation should be recommended.

So that medical priority classification be of practical importance, a blank space is placed on our Individual Educational Program form where the medical priority designation is entered. This alerts program managers to


needed service in the medical area, and appropriate staff can be assigned.

To repeat, to ensure optimum use of medical information obtained, all forms dealing with the summary should have a designated place to note the medical component. Another example is Edmonds’ “Special Education Mainstreaming Checklist.” One separate item is “Special Medical Considerations regarding safety, adaptation of program, and medica- t ion. ”

To keep optimum medical components in the program, some staff with belief in the importance of this contribution and with some knowledge in fields of both education and medicine must be included in deliberations and planning sessions and must contribute to plans and solutions. School administrators must be willing to accept this help and be cognizant of the importance of the medical aspect.

SUPPORTIVE RELATIONSHIP A third administrative concern is to maintain a

working and mutually supportive relationship with community physicians. They and their families are part of the clientele served by the school district and are often influential in the formation of community understanding and opinion about the school and its programs. This relationship can be developed through efforts with individuals and through local medical groups (county medical society, local hospital staff). Activities of cooperation on a state level also can influence this relationship. Respect and understanding can be enhanced by planned opportunities for members of the medical and education groups to meet each other as human beings - at no-host breakfasts or lunches with no special agenda except getting acquainted.

When plans and programs are contemplated that have medical aspects or might affect the relationship of a student with his physician, official medical opinion should be sought from a physician representing the local medical group. Our local hospital staff is the group most concerned with medical care of the children in our district, and when a medical advisory group to our services was requested, the Pediatric Committee of the Staff was designated.

Periodic interchanges of information about students between school and physiciaps are helpful in fostering this relationship. Obvious points of contact occur yearly when instructions for occupational and physical therapy are renewed. In addition to these, when a physician has shown a particular interest in the special education of a student, the physician is notified of the placement, including the school, teacher’s name and how to reach the teacher. Also, brief yearly progress reports for physicians are prepared on students with prominent medical components in problems presented.


In the group of children with behavior problems, there are a number receiving psychiatric care from clinic and private sources. Since particularly close communication is desired, we worked with the psychiatrists in our area to develop an informational interchange sheet providing the psychiatrists with observations they wish and the teachers and psychologists at school the help they want on a regular basis.

To be effective, efforts toward continuing and developing relationships must be on a planned basis and the assigned responsibility of a member of the school staff. The staff member should be knowledgeable about state and national trends, efforts and activities toward cooperation of school and medical services, and participate in these when possible.

COSTS A fourth administrative concern is the cost of

obtaining and using needed or desired medical information. This factor is likely to become of increasing concern if the sections in P.L. 94-142 requiring and defining related services are interpreted to mean that all medical evaluation for assessment must be paid by the school district. There are many items in the regulations that are ambiguous in regard to medical involvment and participation; and if interpreted in certain ways, this could lead to financial disaster for special education programs.

For example, under related services, the law includes medical service, specifying that “such medical services shall be required to assist a handicapped child to benefit from special education, and includes the early identification and assessment of handicapping conditions in children.’’ Rules and regulations as of August 23, 1977 include under related services, medical services “for diagnostic or evaluation services” (1 8 1 a. 13) and define medical services as “services provided by a licensed physician to determine a child’s medically related handicapping condition which results in the child’s need for special education and related services (121a.13(4) ),” Later comment at the end of “special education” (121a. 14) states “therefore if a child does not need special education, there can be no “related services” and the child (because not “handicapped”) is not covered under the Act.” With these requirements and definitions, it is difficult to determine which medical services are eligible for payment and seems to leave unanswered the problem of evaluation costs for children found to be not handicapped according to any given definition.

It is important that the federal rules and regulations be carefully analyzed. The interpretation used for implementation of P.L. 94-142 could set precedents which might have serious effects on future operational procedures and costs of programs.

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Rules and regulations of the education for all law in the State of Washington formerly specified that medical diagnostic and treatment services be paid by private means; thus, efforts have been made to strengthen and use public and private resources in the state. This has been a sounder procedure than setting up qualifications for physicians, fee schedules for payment, acceptable standards for medical evaluation, mechanisms with school districts for checking above qualifications and for making payment of services.

Rules and regulations of the State of Washington law (WAC 392-171-065) stated (before P.L. 94-142 forced a change):

(a) Medical consultation is recommended when a child is under consideration as a possible special education candidate, with annual evaluations sub- sequently and whenever the child’s performance or behavior changes significantly.

(b) When as part of a school district’s special education program, an activity is planned which might put an unusual stress upon a child or could complicate an existing condition, written medical clearance by a licensed physician shall be required to show that within knowledge of medical practice, the child will not be harmed. If such medical consultation shall reveal any limiting disability of a medical nature, the teacher shall receive, in writing, specific instructions concerning such limitation(s).

This interpretation allows for more continuity of medical services for a child and for choice of service source by a family. Also, a need for developing judgment within a school staff as to why, when and how medical contribution is obtained is clearly demon- strated.

By whatever means medical evaluation is financed, development of an “interpretive” service within the schools is necessary for the most useful and helpful medical contribution to the program. Provision of staff to build and participate in this service is clearly an administrative concern.

SUMMARY

In this discussion of four administrative concerns, there has been an effort to suggest school-sponsored activities leading to close productive relationships with community physicians and optimum use of medical information available for maintaining adequate medical component in the school management of children with handicapping conditions. A recurring theme is that to attack these concerns, there must be administrative leadership which sees them as important and knowledgeable staff members who are available, assigned and supported to perform the necessary task.

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PUBLIC LAW 94-142 Several other sections in P.L. 94-142 and the Federal

Register which are unclear regarding medical involvement and pose questions about those statements should be discussed.

DETERMINATION OF HANDICAP 121a.5 Handicapped Children

(a) As used in this part, the term “handicapped children” means those children evaluated in accordance with 121a.530-121a.534. . . 121a.532 Evaluation procedures

( f ) The child is assessed in all areas related to the suspected disability, including, where appropriate, health, vision, hearing, social and emotional status and motor abilities. QUESTIONS: How is it to be determined “where appropriate” to include a “health” assessment? Could this be covered adequately by the kind of screening dohe in Edmonds? Will this be interpreted as a ‘>physical examination” necessary for all children? What is acceptable as a “health assessment”? 121a.S[b] [6] “orthopedically impaired” means a severe orthopedic problem which adversely affects a child’s educational performance. The term includes impairments caused by congenital anomaly (club foot, absence of some member), impairments caused by disease (poliomyelitis, bone tuberculosis), and impairments from other causes (cerebral palsy, amputations and fractures or burns which cause contractures). QUESTION: Is this to require a direct statement from a physician to determine etiology of defect? 121a.S[b] [7l “Other impaired” means limited strength, vitality or alertness due to chronic or acute health problems - such as a heart condition, tuberculosis, rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia or diabetes - which adversely affect a child’s educational performance. QUESTION: Is this to require a direct statement from a physician ? 121a.5[b] [S] “seriously emotionally disturbed’’ is de- fined as follows:

(A) An inability to learn which cannot be explained by intellectual, sensory or health factors.

(E) A tendency to develop physical symptoms or fears associated with personal or school problems. QUESTION: Is this to require medical statement to rule out “‘health factors”? 121a.5 [9] “Specific learning disability” includes such conditions as brain injury, minimal brain dysfunction, dyslexia and developmental aphasia. The term does not include problems which are primarily the result of visual, hearing or motor handicaps.

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QUESTION: Is this to require medical statement to label “brain injury, minimal brain dysfunction . .”? 121a.5 [ll] “Visually handicapped” means a visual impairment which, even with correction, adversely affects a child’s educational performance. QUESTION: Who is to determine whether correction is to optimum level?

RELATED SERVICES 121a.13 Related services

(b) (1) Autiology includes (ii) Determination of range, nature and degree of hearing loss, including referral for medical or other professional attention for the habilitation of hearing.

(12) Speech pathology included (iii) Referral for medical or other professional attention necessary for the habilitation of speech or language disorders. QUESTIONS: Does “referral for medical or other professional attention” imply that medical services as a result of referral are reimbursable? Actually these services would be provided after the child had already qualified for the diagnostic category, so would this meet requirements that service be “to determine a child’s need for special education . . . services” as specified in I2la. I3(b) (4)?

PLACEMENT 121a.533 Placement procedures

(a) In interpreting evaluation data and in making placement decisions, each public agency shall: (1) Draw upon information from a variety of sources, and (2) Ensure that information obtained from all of these sources is documented and carefully considered. QUESTION: What is to be considered an adequate review of ‘physical condition”? Whose opinion will be sought and how? Is this likely to be interpreted as requiring a ‘physical examination” on all students?

EVALUATION AND RE-EVALUATION 121a.532 Evaluation procedures

State and local educational agencies shall ensure at a minimum that: (e) The evaluation is made by a multidisciplinary team or group of persons, including at least one teacher or other specialist with knowledge in the area of suspected disability, and (f) the child is assessed in all areas related to the suspected disability, including, where appropriate, health, vision, hearing and motor abilities. QUESTION: How is it’ to be determined ‘“where appropriate” for a “health evaluation”? What b this to be? 121a.534 Re-evaluation

Each state and local educational agency shall ensure (b) that an evaluation of the child based on procedures which meet the requirements under 121a.532 is conducted every 3 years or more frequently if conditions


warrant, or if the child’s parent or teacher requests an evaluation. QUESTIONS: If medical services for “evaluation purposes” are considered the responsibility of the school, does this include evaluation at the time of re- evaluation? If medical treatment services have been provided by different medical resources than those conducting the evaluation, how are these to be co- ordinated? Does service provided at this time meet the requirements in 12la.I3(b) (4) “to determine a child’s need for special educational services”?

QUALIFICATIONS 121a.12 Qualified

As used in this part, the term “qualified” means that a person has met state educational agency approved or recognized certification, licensing, registration or other comparable requirements which apply to the area in which he or she is providing special education or related services. 121a.13 Related services

(b) (4) “Medical services” means services provided by a licensed physician. QUESTION: Which definition in regard to qualifca- tions of physicians are to be used?

CHILD IDENTIFICATION 121a.220 Child identification

Each application must include procedures which ensure that all children residing within the jurisdiction of the local educational agency who are handicapped, regardless of the severity of their handicap, and who are in need of special education and related services are identified, located and evaluated, including a practical method of determining which children are currently receiving needed special education and related services. QUESTIONS: How will practicing physicians fit into this plan? Will evaluative services be the financial responsibility of the school districts?

STATE PLAN 94-142 89 Stat. 781

(7) The state shall assure that (A) in carrying out the requirements of this section, procedures are established for consultation with individuals involved in or concerned with the education of handicapped children. 94-142 89 Stat. 783

(12) Provide that the state has an advisory panel appointed by the governor or composed of individuals involved in or concerned with the education of handicapped children.

R&R 121a.651 Membership

be composed . . . (a) The membership of the state advisory panel must

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(b) The state may expand the advisory panel to include additional persons . . . QUESTION: Are practicing physicians going to be routinely included because of their interest and involvement with students in their practices?

CONCLUSION The answers to these questions may have a great

influence on the relationship between schools and practicing physicians. Even more important is the possible effect on special education programs available for the children. It would seem wise, therefore, to have some clarification on a national level as to what are acceptable answers before we find ourselves operating according to precedents set by court decisions. Time is running out. Already demands are being made by alert parents and attorneys for payment of medical evaluative services. We must see that our school administrators have read these sections of the law carefully and are aware of the implications and potential financial involvement and are insisting that acceptable procedures and processes be developed to save the total educational program. Our advice in these areas is needed.

Finally - The job of those of us in the health professions seems to be to continue recognizing opportunities for service, demonstrating our value in enhancing programs for children and believing that our contributions are important in order to keep up our own courage.

BIBLIOGRAPHY Glaser K, Clemens RL: School failure. Pediatrics 35:(No. 1) Part I .

Mankes JH: On failing in school. Pediutrics 58:OJo. 3) 392, 1976. Boder, E: School failure - evaluation and treatment. Pediatrics 58:

(No. 3 ) 394, 1976. Bax MCO: The assessment of the child at school entry. Pediatrics 58

(No. 3 ) 403, 1976. Denhoff E: Learning disabilities: an office approach. Pediatrics 58:

(No. 3 ) 409, 1976. Bryan E, Harlin V. Phips Z, et al: The school physician in special

education programs. J Sch Health 47:486 October, 1977. Bryan E. Warden M, Berg B. et al: Medical considerations for multi-

ple-handicapped children in the public schools. J Sch Health 48:84. February 1978.

Beck E, Edgar E, Kenowitz L: The physician - Educator Team - let’s make it work. J Sch Health 48:79, February, 1978.

Bryan E: Medical Componet of the I.E.P., Conference Paper, CEC Institute on I.E.P., Alburquerque, February 1978.

Nader P: Options for School Health. Aspen Systems Corporation, Maryland, 1978. Public Law 94-142,94th Congress, 5-6, November 29, 1975.

1965.

Congressional Federal Register 42: August 23. 1977. State of Wmhington Rules Regulations for Programs Providing

Services to Children With Handicapping Conditions, Chapter 392- 171 WAC (originally adopted July 1975, modified and’adopted 9/24/1976).

Committee on School Health: Medical emergencies and administration of medication in school. Pediatrics 61:(No. I), 1978.

Elizabeth Bryan, MD, consultant to School Health Committee of King County Medical Society and school physician, Special Services Division, Edmonds School District, 8500 200th Street S W, Edmonds, WA 08020.


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