According to the U.S. Department of Education National Center for Educational Statistics, the number of students with disabilities enrolled in undergraduate degree programs is growing — from 6 percent in 1995–96 to 11 percent in 2011–12. These figures are also increasing in professional and graduate degree programs. The 2010 DOE-NCES data showed that 7.6 percent of students in such programs self-reported a disability. Anecdotally, disability services providers understand that these numbers continue to grow. Qualified college graduates with disabilities, like many of their peers, are applying to graduate programs in the health sciences. Current research out of the University of California, San Francisco School of Medicine seeks to determine the prevalence of students with disabilities studying medicine in the United States. Preliminary data analysis suggests that between 1 and 12 percent of students currently enrolled in these programs identify as students with disabilities. Providers with disabilities remain an underrepresented minority in the health care workforce, with the numbers being disproportionate to the magnitude of disabled people in the U.S. population.
The need for culturally competent practitioners
The Disability Rights Education Defense Fund’s Welcome to Health Care Stories series and Disability and Health: Fact Sheet Number 352 from the World Health Organization confirm that disabled people face a variety of barriers to accessing health care. Among these are attitudinal barriers, such as assumptions related to the individual’s underlying medical and nonmedical needs; communication barriers, including the absence of sign-language interpretation, or the inability to facilitate modified communication strategies; and physical barriers, such as the lack of height-adjustable exam tables, accessible mammogram machines, and accessible scales.
The Association of American Medical Colleges predicts a shortage of more than 91,000 physicians by 2020. Given the US Census Bureau’s data reporting that approximately 56 million, or 19 percent, of Americans have disabilities — a substantial and growing number — there exist pragmatic benefits to having disabled physicians included in the health care workforce. They bring “cultural competence” to the practice of medicine, garnered through their lived experience of disability. In keeping with existing efforts within the medical profession to increase the diversity of its workforce, U.S. medical schools are taking great strides to admit and appropriately accommodate students with disabilities.
Medical education and disability
The field of medicine changes rapidly. With a long-standing commitment to innovation and discovery, medical professionals have long questioned the status quo to develop more effective treatments that save lives and enhance quality of life for patients. Similarly, advances in assistive technology have facilitated greater access to health science and medical education programs for a whole cadre of students with disabilities. However, these advances, combined with legally mandated accommodations, have yet to spark an enthusiastic reception within the medical profession. Substantial barriers persist that exclude people with disabilities from medical education and practice. These are often attitudinal in nature, or the consequence of a medical culture that expects perfection of physicians and therefore construes people with disabilities as inherently less capable of practicing medicine.
Recent legal decisions drive increased access
Regardless of whether professional schools and health science programs adopt a proactive commitment to students with disabilities, these students are entering programs in growing numbers, and the courts are supporting their right to an accessible education. Recent legal rulings suggest that courts’ past deference to academic decisions is beginning to wane. Health science programs are also being required to provide accommodations for individuals with sensory (visual or hearing) disabilities, which were not mandated previously. Both of these trends are evident in the cases Palmer College of Chiropractic v. Davenport Civil Rights Commission (850 NW2d 326 (Iowa 2014)) and Featherstone v. Pacific Northwest University of Health Sciences (2014 WL 3640803 (E.D. Wash. 2014)). In the Palmer case, the Iowa Supreme Court ordered the nation’s leading chiropractic college to provide disability accommodations that the college argued would fundamentally alter their educational standards. The court ruled that a blind student should be granted an aide to read radiographs and rejected the school’s assertion that eyesight is a requirement for the profession and that it would “fundamentally alter” educational standards, as many chiropractors rely on outside experts to evaluate X-ray images. Similarly, in the Featherstone case, where a university revoked admission to a deaf student, a court found that the use of American Sign Language interpreters in medical education would not cause a fundamental alteration to the educational program, nor compromise patient safety. The court ordered that the medical school admit the student, who began classes in the fall of 2014. These decisions are leading health science campuses across the nation to make changes in policy that facilitate greater access for students with disabilities.
The need for specialized providers
Specialization of disability services 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.
First, students working in these environments must adhere to strict technical standards, while demonstrating exceptional ability to work independently and as part of a team. At the same time, advanced communication skills become essential. Students must effectively communicate with patients and other practitioners on a number of topics. They are often expected to identify and interpret a variety of visual, auditory and tactile information acquired through patient interviews, physical exams, imaging and lab results — all of which may be aggregated in electronic (e.g., electronic health records) or nonelectronic formats.
Second, when assistive technology is needed in the clinical setting, it is important to understand how it may impact patient safety and confidentiality (i.e., compliance with the Health Insurance Portability and Accountability Act).
Third, communication related to one’s disability becomes more nuanced because students in clinical settings must reach multiple individuals in large hierarchical settings. These students may also incur greater scrutiny about their accommodations, and their status as a student with a disability. This can result in a hesitation to disclose or seek accommodation in the competitive, fast-paced settings of the health sciences and medical education.
Training in the clinic
A critical part of being a disability services provider in the health sciences is having a deep understanding of the program and the demands therein. To identify possible accommodation solutions, providers 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. They must also identify reasonable and creative accommodations that eliminate barriers, uphold technical standards, and do not risk patient safety. The aforementioned tasks require that disability services providers in health science programs understand the curriculum structure, technical standards, lexicon of the program, clinical requirements including how placements are made, core clerkship rotations, culture of clerkship sites, and clerkship requirements or competencies. When disability services providers understand the clinical setting and the demands of undergraduate and graduate medical education, they build credibility with school administration, clinical faculty and students, and yield better results for students.
Evidence-based research and practice
Disability services and accommodations have not been well-researched in the health sciences. Decisions about which accommodations to use, for whom, and under what clinical conditions are based on limited empirical evidence regarding their effectiveness and validity. As such, there is an urgent need for evidence-based research and practice. By integrating clinical expertise, expert opinion, scientific research, and the lived experiences of the student with disabilities and the patient receiving care, disability services providers can develop a well-informed list of best practices.
A commitment to empirically supported accommodations
Institutions are making concerted efforts to address these needs. Recently, two preeminent institutions — the University of California, San Francisco School of Medicine and Stanford University — appointed research practitioners to focus on evidence-based research around accommodations in higher education and in the health sciences. These newly created positions will be dedicated to working with students with disabilities and leading research and public scholarship in this and related areas. Both institutions are committed to supporting students with disabilities and to identifying innovative accommodations that reduce barriers for students with disabilities in medical education. Their shared goal is to develop a set of best practices grounded in empirical evidence.
Growing the commitment
As an increasing number of institutions recognize the need for specialization and the benefit of including disability as part of a greater commitment to diversity, we anticipate that disability services providers with a specialization in health sciences will become part of the normal landscape and a critical part of the education team. Confronting obstacles in health care and seeking ways to improve upon them, however, is the sine qua non of medicine. For students with disabilities, crafting innovative solutions to surmount everyday barriers is nothing new. What they bring to the health care workforce is a creative mindset to the procedures required of physicians in addition to a natural empathy for patients challenged by the functional implications of their diseases. The time is ripe for fresh thinking about how to develop effective accommodation strategies that enable students with disabilities to pursue their chosen professions and make lasting differences in health care.
Thanks to Dr. Gregory Moorehead, vice president of the Coalition for Disability Access in Health Science and Medical Education and director at the University of Chicago. Parts of his interview with NPR were adapted for this article.
Thanks also to Elisa Laird-Metke, Esq., legal advisor to the coalition and director at Samuel Merritt University, for reviewing legal references in this article.
From the Editor
Disability Compliance for Higher Education is committed to informing our membership about best practices in health science programs and has partnered with the Coalition for Disability Access in Health Science and Medical Education to bring the readers a monthly column that will address the nuanced and specialized practices in this area. Each month, a guest writer from the coalition will bring tested and sage advice to the readers from some of the most experienced disability services providers in the country. This column will begin in the January issue.