Updated December 1, 2021. The article was updated to correct minor grammatical errors and to update formatting.
Medical school, for some, remains the ultimate “glass ceiling” — the unseen yet unbreakable barrier that stands in front of one’s dream career as a physician, regardless of his or her qualifications and achievements. Medicine still employs the “medical model” of disability, meaning that disabilities represent a deficit of sorts, and are something to be “fixed” or “cured.” The physician or medical professional has a job — to cure or heal the deficit. This message is repeated throughout medical programs and serves as a reinforcement that students will not be qualified providers if they have a disability and need to be fixed.
What are the barriers?
One of the most significant barriers for health sciences and medical students with disabilities is fear. Fear of stigma is very real. The perceived stigma of having a disability and utilizing accommodations places tremendous pressure on students with disabilities. This often leads them to forgo disclosure of disability and accommodations in an effort to minimize any visible differences between them and their peers.
Health science and medical programs are extremely competitive. This leads to another barrier when requesting and receiving accommodations: shame. Many students with disabilities are ashamed that they need accommodations; they fear that their accommodations are viewed as an unfair advantage, or “gaming the system.” They may feel embarrassed or devalued by some of their peers, staff, and faculty. Students with disabilities may also personalize any stigma or criticism and feel their progress or success is somehow devalued when compared to that of their peers.
Confidentiality is also a large barrier for students with disabilities (SWD) in medical school. SWD often are fearful that their disability and accommodations will somehow become part of their permanent record and could impact their ability to match into residency or become employed or licensed. Until recently, accommodated exams (MCAT and NBME exams) included flags or notations that indicated an exam was given under non-standard conditions. This was a major factor in students’ refusal to disclose disabilities and request accommodations for those exams.
Students did not want medical schools, residency programs, or employers to know they had received accommodations for fear that their performance would somehow be devalued, or evaluated differently than that of their peers.
What can medical education do to remove barriers?
Adopt proactive commitments to students with disabilities.
Medical students with disabilities are entering programs in growing numbers, and recent court decisions and OCR findings are supporting student access to medical education. Programs should not wait for legal action to motivate their accessibility. Instead, they should take a proactive stance to ensure that their programs are accessible to students with disabilities by removing physical, cultural, and attitudinal barriers. Removing barriers can be accomplished through education and understanding, policy development, and transparency.
Programs should become educated, and work to understand their responsibilities under the Americans with Disabilities Act (ADA). This education should not be relegated to one individual; rather, the entire campus needs to have an understanding of their collective responsibility to ensure access. This includes administrators, faculty, and information technology staff.
Understand advances in assistive technology
Advances in assistive technology have grown at an astonishing rate and have improved accessibility in both the didactic and clinical settings; however, medical schools remain unaware of these products. Medical schools should work with their educational technology staff to better understand these advances and how they might provide greater access to students with disabilities.
Hire specialized providers
Specialization of disability providers is critical when working with students in health science programs. The clinical components of education present unique challenges for students that are not adequately addressed by traditional accommodations employed in didactic classroom settings. Strict technical standards, advanced communication skills, and the need to identify and interpret a variety of visual, auditory, and tactile information are essential tools in assessing patient interviews, physical exams, imaging, and lab results. All of these factors contribute to the need for specialized providers. A critical part of being a disability provider in the health sciences is having a deep understanding of the program and the demands therein.
In order to identify possible accommodation solutions, the provider must be prepared to work alongside the student and clinical faculty to anticipate barriers based on the student’s disability-related functional limitations and the requirements of the program. The provider must identify reasonable and creative accommodations that eliminate barriers and uphold technical standards, without risking patient safety.
Disability providers in health science programs must understand the curriculum structure, technical standards, and lexicon of the program, with the clinical requirements including core clerkship rotations, the culture of clerkship sites, clerkship requirements/competencies, and how placements are made. When disability providers understand the clinical setting and the demands of undergraduate and graduate medical education, it results in better service and accessibility for students.
Develop clear policies and procedures
It is important to have clear policies and procedures at application, admission, and throughout a student’s medical education experience to ensure a clear understanding of how disability is handled in a medical program. This should include the contact information for the major stakeholders, including program coordinators, program liaisons, and specific instructions for students on whom to contact and when.
Visibility of the office philosophy and policies is important, as it highlights the campus’ commitment to diversity (including disability as an aspect of diversity), sets a welcoming tone, and lets prospective students know that students with disabilities are expected and resources are available to ensure equitable access for qualified students.
Giving students clear guidance on how, and to whom, to disclose their disability demonstrates a commitment to the process and to ensuring accessibility. Having disability information and policies readily available communicates to prospective and current students alike that there are students with visible and invisible disabilities in the program, normalizing disability as one facet of diversity on campus.
Equally important is articulating the process for receiving accommodations. These instructions should be specific to the type of accommodation (e.g., didactic exams, USMLE step exams, shelf exams, and various standardized patient exams).
The policy and workflow for requesting, scheduling, and implementing accommodations should be in writing and made available to students, clerkship directors, and faculty in core courses. Each party must understand his or her respective responsibility in the process.
When students and faculty understand their roles in the process and this information is clearly delineated, it reduces confusion, supports disclosure, and establishes consistency in working with students with disabilities, thus eliminating subjective approaches to accommodating students.
A broader commitment to disability as an issue of diversity
Despite the current focus on diversity in medicine overall, disability—laws, best practices, meeting technical standards, and the contribution to diversity by individuals with disabilities—is largely unaddressed. Existing efforts to meet the nuanced needs of this population are grounded in the professional experiences of disability providers, interested faculty, and experts, but fail to reach the critical attention afforded to other diversity agendas.
Stigma and stereotypes continue to misinform our understanding of individuals with disabilities. The most impactful method for eroding these stereotypes is exposure to a disability during training, residency, and practice. This exposure is most impactful when it is peer-to-peer. Drs. Iezzoni and Long-Bellil suggest that “Perhaps the most dramatic learning can come when it is a peer who is disabled, rather than a patient. Learning alongside a student who is a wheelchair user or has restricted growth or is deaf can challenge negative assumptions directly, as well as broaden the pool of qualified people entering the health profession.”
The Association of American Medical Colleges (AAMC) is heeding the call for education around disability. The AAMC’s current initiatives include a Group on Student Affairs webinar series in partnership with the University of California, San Francisco School of Medicine, and the Coalition for Disability Access in Health Science and Medical Education. These webinars focus on disability in health science professions and have drawn the largest audience of any AAMC webinars to date, which serves as evidence of the need for this information.
In addition, disability has been given a platform at regional and national AAMC meetings. The Reporter, the AAMC’s flagship news publication, recently ran an article titled, “The New Normal,” highlighting efforts around the country to remove barriers to medical education for individuals with disabilities.
Finally, a newly formed coalition, The Coalition for Disability Access in Health Science and Medical Education is working to educate medical and other health science programs through books, articles, and student resources. In its third year, the coalition boasts over 150 members representing over 100 medical and health science programs across the nation. Each year they host a symposium that brings together providers in the field for advanced training and an exchange of information with the ultimate goal of removing barriers and building inclusive health science programs. Last spring, several members of the coalition contributed to a newly published resource, The Guide to Assisting Students With Disabilities: Equal Access in Health Science and Professional Education.
Where do we go from here?
Medicine is moving toward a focus on diversity as a critical and valuable addition to the physician workforce. Cultural competence has made its way to the forefront of medical education. As the US has become more diverse, the awareness of the impact of cultural awareness on medical outcomes has become more profound and instruction on cultural competence with regard to disability is more relevant than ever.
A renewed focus on disability as a function of diversity, high profile lawsuits against medical schools and the NIH’s mandatory reporting efforts around disability recruitment and retention have pushed disability into the spotlight. The field is hungry for more information and making disability a priority begins with a truly informed understanding of the experiences of, and the supports needed by, students with disabilities.
Unfortunately, while approximately 20% of the U.S. population has a disability, it is estimated that less than 1% of students with disabilities make up the medical school graduating classes. Admitting more students with disabilities to medical school will normalize disability within the institution, diminish the stigma associated with disabilities, and unleash tremendous potential for innovation and research. We must do more to ensure our institutions are accessible to students with disabilities by maintaining clear policies and identifying experienced providers who understand medicine and the available resources, and who are well situated to support both the school and the student to ensure equal access.