Call to Action: Eliminate Barriers Faced by Medical Students With Disabilities

“NOTHING ABOUT US WITHOUT US”

Over 61 million Americans with disabilities face troubling health care disparities.¹ The landmark Americans with Disabilities Act (ADA) of 1990 requires that health care entities provide equal access to care for persons with disabilities (PWD).² But in a 2021 survey, only 40.7% of physicians feel confident they provide the same level of care to persons with disabilities as those without.¹

One in 5 patients reports a disability,¹ yet only 1 in 33 physicians in the United States identifies as having a disability.³ To provide equitable health care for people with disabilities we must heed the rallying cry of the disability rights movement: “Nothing about us without us.” The American Medical Association (AMA) agrees. A recent AMA report recognizes that concordance between patients and physicians with disabilities is key to addressing inequities for PWD.⁴

This article describes barriers faced by prospective medical students with disabilities as well as opportunities to promote a more just and diverse workforce mirroring the patient population. We call for changes to current medical school admission processes and curricula to increase the number of physicians who identify as having a disability and who may require accommodations to practice.

IMPLICIT BIAS IN THE MEDICAL COMMUNITY—ABLEISM

The medical community historically viewed disability as a pathology and an impairment.¹ Ableism is rooted in the assumption that people with disabilities require fixing and often takes the form of social prejudice by characterizing PWD as inferior to people without disabilities. These perceptions continue to negatively influence medical clinician attitudes about the lives, values, and expectations of people with disabilities.⁵ For example, only 18% of physicians believe they would be glad to be alive after a severe Spinal Cord Injury/Disorder (SCI/D) vs 92% of people with SCI/D.⁶ And 82% of doctors believe the quality of life of people with disabilities is either “a little worse” or “a lot worse” than those without.¹

While 80% of physicians strongly agree it is very valuable to understand their patients with disabilities, only 18% strongly agreed that people with disabilities are treated unfairly in the health care system.¹ In fact, PWD face persistent gaps in screening and preventative services, reproductive and pregnancy care, and communication with clinicians.¹ Further, the World Report on Disability reports stigmatized views of disability infiltrate patient-physician communication and adversely compromise patient care.⁷

Diversity among physicians is essential to address attitudinal barriers, combat bias, and build empathy. When people with disabilities are viewed only as subjects to be studied and treated, negative attitudes and false stereotypes will likely continue.⁸ One way to counter bias against outsiders (ie, what many consider PWD), is to make them insiders (physicians).⁸ Former president of the American Association of Medical Colleges (AAMC), Jordon Cohen, acknowledged the importance of diversifying the health care workforce stating, “Future physicians can acquire the necessary attributes only by being educated in the company of a broadly diverse student body and in learning environments that reflect the diverse society they will be called upon to serve.”⁹ To equitably serve the 61 million Americans with disabilities, the medical community must address its implicit bias toward ableism by taking action to increase the number of medical students with disabilities. When health care clinicians share similar life experiences with patients, patients tend to be more satisfied with their care and to adhere to medical advice.⁵ Thus, physicians’ personal experiences with the medical system may lead to better patient care.

MEDICAL SCHOOL BARRIERS

The path to medical school is difficult for any student, but people with disabilities face numerous barriers. According to a practicing physician (O. O. Okanlami, MD, MS) who suffered a paralyzing spinal cord injury during residency, the reason there are so few doctors with disabilities “is not because we’re not qualified. It is because we’re waiting outside, without a ramp, just to get a seat at the table.”

A 2016 study found that only 2.7% of US medical students self-reported a disability to their institutions: ADHD, learning, and psychological disabilities were the most prevalent.⁵ The actual number of students with disabilities is likely underreported due to fear of disclosure in the high-stakes and “grind culture” of medicine. This means that many students who need accommodations are unsupported.⁵ A 2009 study found that two-thirds of students with disabilities had not sought support despite experiencing disability-related difficulties in their training.⁵

Several barriers exist for medical students with disabilities including: (1) Exclusionary technical standards, ie, criteria defined by individual institutions for medical school admission which require applicants to “demonstrate certain physical, cognitive, behavioral, and sensory abilities without assistance”⁴; (2) lack of standardization in the disability disclosure and accommodation processes⁵; and (3) inconsistent disability support systems including a lack of specialized knowledge about accommodations among disability resource professionals.⁵ The 2018 AAMC report on disability provided specific guidance to medical schools about the structure of student disability disclosure; however, a 2020 survey found that 35% of medical school practices did not align with the recommendations.¹⁰

REMOVING BARRIERS FOR PRACTICING PHYSICIANS WITH DISABILITIES

The AMA’s Council on Ethical and Judicial Affairs (CEJA) emphasizes that removing barriers to practice and providing accommodations is ethically required and promotes a more just and diverse workforce.⁴ Historically, CEJA did not clearly distinguish being impaired from having a disability or acknowledge the fact that not all illness or disability leads to impairment. Fortunately, in June 2021, the AMA adopted new guidelines, which clarify impairment.⁴ An impairment is now a functional classification defined as a “physical or mental health condition that interferes with a physician’s ability to engage safely in professional activities...” This destigmatizes conditions that can interfere with a physician’s ability to practice safely (ie, substance use, conditions related to aging) and supports physicians who become ill or have a disability but are capable of safe and effective practice with appropriate accommodations or treatment.⁴

CALL TO ACTION

Thirty years after the passage of the ADA, discrimination against people with disabilities still exists. To achieve diverse medical school classes, including the admission of qualified learners with disabilities, we issue a call-to-action to physicians, health care institutions, and allies of patients with disabilities. Specifically, we call on these groups to advocate that the AMA and AAMC require all medical schools take the following steps:

1. Adjust technical standards used for admission at all medical schools to allow for a focus on results rather than process.

   1. Embrace “functional” technical standards that focus on students’ abilities with or without the use of accommodations or assistive technologies.^4,11

   2. Include disability in any statements welcoming diverse applicants to the medical school.⁵

2. Create a culture that supports universal design in hiring practices and physical workspaces. Everyone benefits from accommodations and universal design. This has been described as the “curb-cut effect,” in reference to wheelchair accessible curbs, which also benefit parents pushing strollers, people wheeling luggage, bikers, and most pedestrians¹²; a study at a Sarasota, Florida shopping mall revealed that 90% of “unencumbered pedestrians” go out of their way to use a curb cut.¹²

3. Provide clear and accessible instructions so that students and faculty with disabilities are aware of how to request accommodations.⁵ To facilitate this, medical schools should designate qualified disability resource professionals to serve as a confidential resource for students and faculty and support the implementation of accommodations.¹⁰ To ensure this happens, the AMA and AAMC should both provide guidance on disability disclosure and mandate that all Liaison Committee on Medical Education (LCME)-accredited schools follow this protocol.

4. Foster a culture which normalizes help-seeking behaviors and facilitates access to wellness services to eliminate stigma within the profession regarding “invisible” illness and disability, including mental health concerns. Recent studies suggest that an estimated 27.2% of medical students are depressed and that 11.1% experience suicidal ideation.⁵

5. Incorporate training about people with disabilities into medical school curriculum within the context of human diversity. Social and cultural environments, such as minority status, socioeconomic class, sex, and sexual orientation, affect health and worsen inequities faced by PWD.¹³ The omission of formal disability health education in medical school has led the US Surgeon General¹⁴ and the World Health Organization⁷ to call for strengthening education regarding care for patients with disabilities. The Medical Students with Disability and Chronic Illness organization urges the LCME to recognize that the absence of disability training in medical education is a human rights and social justice issue that jeopardizes the health of the largest minority group in the United States.”¹⁵

CONCLUSION

Physicians with disabilities bring unique insights to the medical field from their personal experience which can directly benefit both patients and colleagues by providing patient-centered care with greater empathy,⁴ addressing attitudinal barriers to care, and creating a more culturally competent workforce. These physicians are an essential component of a medical system which respects persons with disabilities.⁸ But medical students with disabilities face numerous challenges including ableism, barriers to medical school entry, and lack of accommodations. It is time for the academic medical community to recognize and eliminate these barriers.