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

When physicians have a disability or chronic condition, they can offer deeper insight and ability into managing the needs of patients with similar conditions. Yet an alarming 2021 survey found that only 40.7% of physicians feel confident that they provide the same level of care to people with disabilities (PWD) as those without. This may contribute to troubling health care disparities for the over 61 million Americans living with disabilities. In a recent report, The American Medical Association (AMA) recognized that increased concordance between patients and physicians with disabilities is key to resolving health care inequities for PWD, yet although 1 in 5 patients reports a disability, only 1 in 33 physicians identifies as such. This is because prospective medical students with disabilities face many barriers in medical education and practice. We call for specific changes to medical school admission processes and curricula to promote a more just and diverse workforce which includes more physicians with disabilities.

Roles of Academic Writers in a Department: Benefits, Structures, and Funding.

BACKGROUND AND OBJECTIVES: Despite the prevalence of published opinions about the use of professional academic writers to help disseminate the results of clinical research, particularly opinions about the use of ghost writers, very little information has been published on the possible roles for professional writers within academic medical departments or the mechanisms by which these departments can hire and compensate such writers. To begin addressing this lack of information, the Association of Departments of Family Medicine hosted an online discussion and a subsequent webinar in which we obtained input from three departments of family medicine in the United States regarding their use of academic writers. This discussion revealed three basic models by which academic writers have benefitted these departments: (1) grant writing support, (2) research and academic support for clinical faculty, and (3) departmental communication support. Drawing on specific examples from these institutions, the purpose of this paper is to describe the key support activities, advantages, disadvantages, and funding opportunities for each model for other departments to consider and adapt.

Establishing the First Geriatric Medicine Fellowship Program in Ghana.

As life expectancy in Ghana improves, a large and growing population of older adults require healthcare. Despite governmental support for the care of older adults, there have been no geriatricians and no in-country educational path for those desiring to become specialists in this field. In fact, 23 of 54 countries in sub-Saharan Africa (SSA) lack even a single geriatrician. We describe a novel and collaborative approach used to develop the first geriatric training fellowship in Ghana. Faculty from the Ghana College of Physicians and Surgeons and the University of Michigan worked together to develop a rigorous and evidence-based geriatrics curriculum, based on US standards but adapted to be appropriate for the cultural, economic, educational, and social norms in Ghana. This approach led to a strong training model for care of older adults while also strengthening the ongoing collaboration between the two partner universities in Ghana and the United States. The fellowship has been inaugurated in Ghana and can serve as a concrete educational model for other countries in SSA. J Am Geriatr Soc 67:1718-1723, 2019.

Determinants of Hearing Aid Use Among Older Americans With Hearing Loss.

BACKGROUND AND OBJECTIVES: Hearing loss (HL) is common among older adults and is associated with significant psychosocial, cognitive, and physical sequelae. Hearing aids (HA) can help, but not all individuals with HL use them. This study examines how social determinants may impact HA use. RESEARCH DESIGN AND METHODS: We conducted an explanatory sequential mixed methods study involving a secondary analysis of a nationally representative data set, the Health and Retirement Study (HRS; n = 35,572). This was followed up with 1:1 qualitative interviews (n = 21) with community participants to clarify our findings. Both samples included individuals aged 55 and older with a self-reported HL, with or without HA. The main outcome measure was the proportion of participants with a self-reported HL who use HA. RESULTS AND DISCUSSION: Analysis of HRS data indicated that younger, nonwhite, non-Hispanic, lower income, and less-educated individuals were significantly less likely to use HA than their referent groups (all p values < .001). Area of residence (e.g., urban) were not significantly associated with HA use. Qualitative findings revealed barriers to HA included cost, stigma, vanity, and a general low priority placed on addressing HL by health care providers. Facilitators to obtaining and using HA included family/friend support, knowledge, and adequate insurance coverage for HA. IMPLICATIONS: Many socioeconomic factors hinder individuals' ability to obtain and use HA, but these obstacles appeared to be mitigated in part when insurance plans provided adequate HA coverage, or when their family/friends provided encouragement to use HA.

Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss.

Importance: Hearing loss (HL) is common among older adults and is associated with poorer health and impeded communication. Hearing aids (HAs), while helpful in addressing some of the outcomes of HL, are not covered by Medicare. Objective: To determine whether HA use is associated with health care costs and utilization in older adults. Design, Setting, and Participants: This retrospective cohort study used nationally representative 2013-2014 Medical Expenditure Panel Survey data to evaluate the use of HAs among 1336 adults aged 65 years or older with HL. An inverse propensity score weighting was applied to adjust for potential selection bias between older adults with and without HAs, all of whom reported having HL. The mean treatment outcomes of HA use on health care utilization and costs were estimated. Exposures: Encounter with the US health care system. Main Outcomes and Measures: (1) Total health care, Medicare, and out-of-pocket spending; (2) any emergency department (ED), inpatient, and office visit; and (3) number of ED visits, nights in hospital, and office visits. Results: Of the 1336 individuals included in the study, 574 (43.0%) were women; mean (SD) age was 77 (7) years. Adults without HAs (n = 734) were less educated, had lower income, and were more likely to be from minority subpopulations. The mean treatment outcomes of using HAs per participant were (1) higher total annual health care spending by $1125 (95% CI, $1114 to $1137) and higher out-of-pocket spending by $325 (95% CI, $322 to $326) but lower Medicare spending by $71 (95% CI, -$81 to -$62); (2) lower probability of any ED visit by 2 percentage points (PPs) (24% vs 26%; 95% CI, -2% to -2%) and lower probability of any hospitalization by 2 PPs (20% vs 22%; 95% CI, -3% to -1%) but higher probability of any office visit by 4 PPs (96% vs 92%; 95% CI, 4% to 4%); and (3) 1.40 more office visits (95% CI, 1.39 to 1.41) but 0.46 (5%) fewer number of hospital nights (95% CI, -0.47 to -0.44), with no association with the number of ED visits, if any (95% CI, 0.01 to 0). Conclusions and Relevance: This study demonstrates the beneficial outcomes of use of HAs in reducing the probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital. Although use of HAs reduced total Medicare costs, it significantly increased total and out-of-pocket health care spending. This information may have implications for Medicare regarding covering HAs for patients with HL.

Addressing Mental Health Needs for Deaf Patients Through an Integrated Health Care Model.

Deaf individuals struggle with accessing mental health services because of language and cultural discordance. Our project's purpose was to design and pilot an accessible, integrated mental health program for the Deaf population, scalable for other health centers interested in serving these individuals. Our team addressed several identified barriers to care. The addition of a language-concordant mental health clinician and telemental health appointments helped us better manage Deaf patients' mental health needs. Individual and clinic level data were collected and analyzed. Results demonstrated a significant improvement in the patients' depression and anxiety scores from their baseline to their last documented visit. Patient satisfaction overall was high. Telemental health appears to be a feasible tool to address some of the mental health gaps in the Deaf community. Further studies are needed to demonstrate how this program can be effective within a larger geographical area.

Medical Schools' Willingness to Accommodate Medical Students with Sensory and Physical Disabilities: Ethical Foundations of a Functional Challenge to "Organic" Technical Standards.

Students with sensory and physical disabilities are underrepresented in medical schools despite the availability of assistive technologies and accommodations. Unfortunately, many medical schools have adopted restrictive "organic" technical standards based on deficits rather than on the ability to do the work. Compelling ethical considerations of justice and beneficence should prompt change in this arena. Medical schools should instead embrace "functional" technical standards that permit accommodations for disabilities and update their admissions policies to promote applications from qualified students with disabilities. Medical schools thus should focus on what students with disabilities can do, rather than what they cannot do, because these students further diversify the health care profession and improve our ability to care for an expanding population of patients with disabilities.

Emergency Department utilization among Deaf American Sign Language users.

BACKGROUND: Deaf American Sign Language (ASL) users comprise a linguistic minority population with poor health care access due to communication barriers and low health literacy. Potentially, these health care barriers could increase Emergency Department (ED) use. OBJECTIVE: To compare ED use between deaf and non-deaf patients. METHOD: A retrospective cohort from medical records. The sample was derived from 400 randomly selected charts (200 deaf ASL users and 200 hearing English speakers) from an outpatient primary care health center with a high volume of deaf patients. Abstracted data included patient demographics, insurance, health behavior, and ED use in the past 36 months. RESULTS: Deaf patients were more likely to be never smokers and be insured through Medicaid. In an adjusted analysis, deaf individuals were significantly more likely to use the ED (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.11-3.51) over the prior 36 months. CONCLUSION: Deaf American Sign Language users appear to be at greater odds for elevated ED utilization when compared to the general hearing population. Efforts to further understand the drivers for increased ED utilization among deaf ASL users are much needed.

Hearing Loss: Issues in the Deaf and Hard of Hearing Communities.

Hearing loss can lead to impairments in language and speech acquisition, educational attainment, social development, and reading achievement. More than 90% of deaf and hard of hearing (DHH) children are born to hearing parents who may lack the knowledge or experience to effectively care for a child with hearing loss. Family involvement is crucial for teaching self-advocacy and global communication skills, optimizing social development, and helping DHH individuals understand and manage external attitudes about deafness and hearing loss. American Sign Language is a naturally developed language with an always-expanding lexicon and grammatical structures different from those of English. Teaching spoken English and American Sign Language equally, often called bilingual bimodal education, can enhance academic and reading achievement as well as language and psychosocial development. Formal schooling options for a DHH child include enrollment in a public or private school system (often called inclusion, integration, or mainstreaming), a school for the deaf, or a bilingual school. Individuals with hearing loss experience stereotypes and biases that create disparities in health insurance coverage, health care access, and outcomes of mental and physical conditions. Family physicians should recognize and minimize biases to improve health care in the DHH community.

Breast cancer knowledge and practices among D/deaf women.

BACKGROUND: Limited scientific evidence is available regarding D/deaf women's breast cancer knowledge and early detection practices, as well as about how to increase D/deaf women's breast cancer control practices. OBJECTIVE/HYPOTHESIS: To assess baseline breast cancer knowledge and practices among a sample of D/deaf women recruited into a randomized controlled trial of a breast cancer education program developed for this population. METHODS: A written and signed (American Sign Language) survey was administered to a racially/ethnically diverse sample of 209 D/deaf women, 40+ years old, with lower levels of education, recruited in California between October 2008 and May 2009. RESULTS: There were misconceptions about breast cancer risk factors, screening, and treatment; only 64.2% of respondents correctly identified the purpose of mammography. Mammography in the prior 2 years was reported by 57.3% of the sample, by 69.8% of White women, and by 43.5% of women from other racial/ethnic groups. Rates also varied by education, having seen a physician in the prior year, and type of insurance. CONCLUSIONS: This study underscores significant gaps in breast cancer screening knowledge and practices, communication issues in health care settings, and unmet needs for tailored health information and materials in this population. Challenges faced in conducting the research needed to develop and test such programs are noted.

Assessment of depressive symptoms in deaf persons.

BACKGROUND: Evidence suggests that Deaf people may have a greater prevalence of depressive symptoms. However, it is unclear whether commonly used written screening instruments are accurate with this population because of their unique cultural and linguistic factors. SETTING: Deaf persons (n = 71) residing in southeastern Michigan. METHODS: Subjects completed the Zung Self-Rated Depression Scale in both the written (ZSDS-W) and American Sign Language (ZSDS-S) formats and the Hamilton Depression Scale (HAM-D) in American Sign Language in counterbalanced order, followed by a Test Of Reading Comprehension (TORC). They also provided extensive data on demographic, hearing loss, language use, social and health care use variables. RESULTS: Mean subject age was 52 years, 63% of subjects were women, 95% were Caucasian, and 47% were married (87% to another deaf/hard of hearing person). Thirty percent had a college degree and 20% had less than a 10th grade education. The ZSDS-W and ZSDS-S scores were highly correlated (r = +0.79), although the mean ZSDS-W score was 2.8 points higher (P = .001). The ZSDS-S correlated more highly (r = 0.80) with the HAM-D than the ZSDS-W (r = 0.71). There was a significant interaction effect (P < .001) such that the ZSDS-W and HAM-D were significantly associated among higher literacy subjects (beta = 0.80, P < .001) but not lower literacy subjects (beta = 0.20, P = .183). There were no other significant associations between depression scores and numerous demographic, educational, hearing loss, social or language variables. CONCLUSIONS: Compared with the conventional ZSDS-W, the ZSDS-S more accurately assesses depression severity among deaf persons with lower English literacy. However, given the greater sensitivity of the ZSDS-W and the practical barriers to ZSDS-S in physician practices, further research should determine which modality is best for routine depression screening.

Health care system accessibility. Experiences and perceptions of deaf people.

BACKGROUND: People who are deaf use health care services differently than the general population; little research has been carried out to understand the reasons. OBJECTIVE: To better understand the health care experiences of deaf people who communicate in American Sign Language. DESIGN: Qualitative analyses of focus group discussions in 3 U.S. cities. PARTICIPANTS: Ninety-one deaf adults who communicate primarily in American Sign Language. MEASUREMENTS: We collected information about health care communication and perceptions of clinicians' attitudes. We elicited stories of both positive and negative encounters, as well as recommendations for improving health care. RESULTS: Communication difficulties were ubiquitous. Fear, mistrust, and frustration were prominent in participants' descriptions of health care encounters. Positive experiences were characterized by the presence of medically experienced certified interpreters, health care practitioners with sign language skills, and practitioners who made an effort to improve communication. Many participants acknowledged limited knowledge of their legal rights and did not advocate for themselves. Some participants believed that health care practitioners should learn more about sociocultural aspects of deafness. CONCLUSIONS: Deaf people report difficulties using health care services. Physicians can facilitate change to improve this. Future research should explore the perspective of clinicians when working with deaf people, ways to improve communication, and the impact of programs that teach deaf people self-advocacy skills and about their legal rights.