"We Need a Seismic Shift": Disabled Student Perspectives on Disability Inclusion in U.S. Medical Education.

PURPOSE: Students with disabilities have inequitable access to medical education, despite widespread attention to their inclusion. Although systemic barriers and their adverse effects on medical student performance are well documented, few studies include disabled students' first-person accounts. Existing first-person accounts are limited by their focus predominantly on students who used accommodations. This study bridged these gaps by analyzing a national dataset of medical students with disabilities to understand their perceptions of disability inclusion in U.S. medical education. METHOD: The authors analyzed 674 open-text responses by students with disabilities from the 2019 and 2020 Association of American Medical Colleges Year Two Questionnaire responding to the prompt, "Use the space below if you would like to share anything about your experiences regarding disability and medical school." Following reflexive thematic analysis principles, the authors coded the data using an inductive semantic approach to develop and refine themes. The authors used the political-relational model of disability to interpret themes. RESULTS: Student responses were wide-ranging in experience. The authors identified key dimensions of the medical education system that influenced student experiences: program structure, processes, people, and culture. These dimensions informed the changes students perceived as possible to support their access to education and whether pursuing such change would be acceptable. In turn, students took action to navigate the system, using administrative, social, and internal mechanisms to manage disability. CONCLUSIONS: Key dimensions of medical school affect student experiences of and interactions with disability inclusion, demonstrating the political-relational production of disability. Findings confirm earlier studies on disability inclusion that suggest systemic change is necessary, while adding depth to understand how and why students do not pursue accommodations. On the basis of student accounts, the authors identify existing resources to help medical schools remedy deficits in their systems to improve their disability inclusion practice.

What's your experience?: A duoethnographic dialogue to advance disability inclusion in medical education.

BACKGROUND: Although disability inclusion in medical education is gaining interest internationally, scholarship and policy recommendations on this topic largely hail from the US, Canada, Australia and the UK. Existing scholarship, while calling for medical education to enact cultural and attitudinal change related to disability, has yet to exemplify how educators might critically examine their understandings. APPROACH: As two medical educators and researchers, one based in New Zealand and the other based in Saudi Arabia, we took a duoethnographic approach to explore tensions, possibilities and assumptions regarding disability and disability inclusion in medical education. Through a year-long synchronous and asynchronous dialogue, we examined our experiences in relation to literature from critical disability studies and disability inclusion in medical education. FINDINGS: We present recurrent themes from our dialogue. We consider what disability means, explore definitions and models of disability in our contexts, as well as our lived curriculum of disability. We grapple with the applicability of disability inclusion practices across borders. We explore the complexity of supporting access without a clear roadmap, while recognising educators' potential in this work. Finally, we recognise that, if disability is relational, we have the power and responsibility to address ableism in medical education. Throughout, we return to the importance of local consultation with disabled people (learners, physicians) to better understand how services ought to be oriented. CONCLUSION: Duoethnographic dialogue is a fruitful approach to critically examine understandings of disability with others and represents a necessary start to work in education that seeks to advance justice. We share possible actions to take the work forward beyond dialogue and suggest that readers engage in such dialogues with others in their own contexts.

Legibility: knowing disability in medical education inclusion.

How medical students, their teachers, and school administrators understand disability appears connected to ongoing, unequal access to medical education for disabled people. The stigmatization of disability within medical education affects students' disability disclosures, yet few studies have explored how understandings of disability influence inclusion practices beyond individual student actions. This paper develops the concept of legibility, derived from a constructivist grounded theory study that examined disability inclusion at four U.S. medical schools through interviews with 19 disabled students and 27 school officials (faculty and administrators). With two dimensions (recognition and assessment of possibility), legibility demonstrates that knowing disability is relational, contextual, and equivocal. Drawing from the field of disability studies, the paper argues that the current paradigm of disability inclusion demands that students' disability experiences be highly legible to themselves and others, yet increased legibility comes with potential risk due to prevalent ableism. While individual interactions can shift understandings of disability towards greater inclusivity, systemic action that embeds liberating discourses of disability into medical education is needed.

Exploring Mistreatment of Medical Students by Patients: A Qualitative Study.

PURPOSE: Mistreatment of medical students by patients has not been qualitatively explored in the literature. The authors sought to develop a rich understanding of the impact and consequences of medical students' experiences of mistreatment by patients. METHOD: This exploratory descriptive qualitative study was conducted at a large Canadian medical school from April-November 2020. Fourteen medical students were recruited for semistructured interviews. Students were asked about their experiences of mistreatment by patients and how they responded to these experiences. Transcripts were thematically analyzed using an inductive approach, and the authors interwove critical theory into their conceptual interpretation of the data. RESULTS: Fourteen medical students (median age = 25.5; 10, 71.4% self-reported male; 12, 85.7% self-identified visible minority) participated in this study. Twelve (85.7%) participants had personally experienced patient mistreatment and 2 (14.3%) had witnessed mistreatment of another learner. Medical students described being mistreated by patients based on their gender and race/ethnicity. Although all participants were aware of the institution's official mechanism for reporting mistreatment, none filed an official report. Some participants described turning to their formal (faculty members and residents) and informal (family and friends) social supports to cope with mistreatment by patients. Participants described resenting and avoiding patients who mistreated them and struggling to maintain empathy for, openness to, and overall ethical engagement with discriminatory patients. Students often described a need to be stoic toward their experiences of mistreatment by patients, often seeing it as their "professional duty" to overcome and thus suppress the negative emotions associated with mistreatment. CONCLUSIONS: Medical schools must proactively develop multifaceted mechanisms to support medical students who experience mistreatment by patients. Future research can further uncover this neglected dimension of the hidden curriculum to better develop responses to incidents of mistreatment that commit to antiracism, antisexism, patient care, and learner care.

Compassionate Off-Ramps: The Availability of Terminal Master's Degrees in US Medical Schools.

Medical students who underperform or find they are not a "good fit" for medicine have limited options. A terminal master's degree represents an exit alternative that recognizes students' completed coursework and acknowledges their commitment to the medical sciences. Although medical educators have called for the creation of such programs, termed "compassionate off-ramps," the prevalence of degree offerings in US programs is unknown. In the fall of 2020, a survey was sent to Student Affairs Deans at 141 LCME-accredited MD programs; 73 institutions responded (52%). Terminal master's degrees were offered by 19% of respondent institutions (n = 13). While 85% of those without a terminal master's (n = 48) endorsed degree benefits, only 36% (n = 21) had plans to create the degree. This study demonstrates that few US medical schools offer a terminal master's degree, leaving students who exit medicine with high levels of debt without an avenue for a degree to support employment or future academic pursuits. The authors identify implications for students, particularly those who are at a higher risk of failing Step 1, such as students who are underrepresented in medicine, socioeconomically disadvantaged, or who have a disability and are unaccommodated. Potential barriers to terminal master's program creation are identified and mitigating strategies are recommended.

Disability, program access, empathy and burnout in US medical students: A national study.

OBJECTIVE: The objective of this study is to investigate whether self-disclosed disability and self-reported program access are associated with measures of empathy and burnout in a national sample of US medical students. METHODS: The authors obtained data from students who responded to the Association of Medical Colleges (AAMC) Year 2 Questionnaire (Y2Q) in 2019 and 2020. Data included demographic characteristics, personal variables, learning environment indicators, measures of burnout (Oldenburg Burnout Inventory for Medical Students), empathy (Interpersonal Reactivity Index) and disability-related questions, including self-reported disability, disability category and program access. Associations between disability status, program access, empathy and burnout were assessed using multivariable logistic regression models accounting for YQ2 demographic, personal-related and learning environment measures. RESULTS: Overall, 23 898 (54.2%) provided disability data and were included. Of those, 2438 (10.2%) self-reported a disability. Most medical students with disabilities (SWD) self-reported having program access through accommodations (1215 [49.8%]) or that accommodations were not required for access (824 [33.8%]). Multivariable models identified that compared with students without disabilities, SWD with and without program access presented higher odds of high exhaustion (1.50 [95% CI, 1.34-1.69] and 2.59 [95% CI, 1.93-3.49], respectively) and lower odds of low empathy (0.75 [95% CI, 0.67-.85] and 0.68 [95% CI, 0.52-0.90], respectively). In contrast, multivariable models for disengagement identified that SWD reporting lack of program access presented higher odds of high disengagement compared to students without disabilities (1.43 [95% CI, 1.09-1.87], whereas SWD with program access did not (1.09 [95% CI, 0.97-1.22]). CONCLUSIONS: Despite higher odds of high exhaustion, SWD were less likely to present low empathy regardless of program access, and SWD with program access did not differ from students without disabilities in terms of disengagement. These findings add to our understanding of the characteristics and experiences of SWD including their contributions as empathic future physicians.

The capability imperative: Theorizing ableism in medical education.

Medical education programs profess commitments to justice, equity, and inclusion, seeking to diversify the profession and better serve patient populations. Although disability has more recently joined recognized categories of valued diversity, significant barriers remain for disabled learners in medicine. This paper develops the concept of the capability imperative, derived from a constructivist grounded theory study examining disability inclusion at four U.S. medical schools that analyzed technical standards policies and interviews with 19 disabled students and 27 school officials (faculty and administrators). Through three motifs (the selfless superhuman; the "real world" of medicine; and the malleable student), the capability imperative enforces the characteristics of a good physician, justifies institutional arrangements, and seeks to produce a learner who can conform to these expectations. Drawing on critical disability theories of ableism and crip theory, the paper argues that the capability imperative represents a context-specific manifestation of ableism that upholds a cultural logic of compulsory hyper-ablebodiedness and mindedness. This logic is antithetical to inclusive goals. Exploration of what constitutes a physician and whom this vision serves may help to shift the professional culture towards justice and unroot disabled peoples' ongoing marginalization in the medical profession.

Impact of USMLE Step-1 accommodation denial on US medical schools: A national survey.

INTRODUCTION: In 2019, 4.6% of US-MD students self-identified as students with disabilities (SWD); many of these students will require accommodations on the USMLE Step-1 examination. Given the high-stakes nature of Step-1 for medical school advancement and residency match, SWD denied accommodations on Step-1 face considerable consequences. To date no study has investigated the rate of accommodation denial and its impact on medical school operations. METHODS: To investigate the rate of accommodation denial and evaluate whether Step-1 accommodation denial impacts medical school operations, a 10-question survey was sent to Student Affairs Deans and disability resource professionals at all fully-accredited US-MD granting programs. Two open-ended questions were analyzed using qualitative content analysis. RESULTS: Seventy-three of the 141 schools responded (52%). In the 2018-2019 academic year, 276 students from 73 schools applied for Step-1 accommodations. Of these, 144 (52%) were denied. Of those denied, 74/144 (51%) were delayed entry into the next phase of curriculum and 110/144 (76%) took the Step-1 exam unaccommodated. Of the 110 who took Step-1 without accommodations, 35/110 (32%) failed the exam, and 4/110 (3%) withdrew or were dismissed following exam failure. Schools reported varied investments of time and financial support for students denied accommodations, with most schools investing less than 20 hours (67%) and less than $1,000.00 (69%). Open-responses revealed details regarding the impact of denial on schools and students including frustration with process; financial and human resources allocation; delay in student progression; lack of resourcing and expertise; and emotional and financial burdens on students. DISCUSSION: Step-1 accommodation denial has non-trivial financial, operational, and career impacts on medical schools and students alike. The cause of accommodation denial in this population requires further exploration.

Educating health science students about disability: Teachers' perspectives on curricular gaps.

BACKGROUND: People living with disabilities are significantly more likely than their peers to find health professionals' skills and facilities inadequate. The 66th World Health Assembly called for better health care for people with disabilities including more inclusive health services and a stronger focus on professional training. OBJECTIVE: To explore how teachers at a New Zealand university perceived the need, approaches, and systemic challenges to enhance disability education for health professionals in training. METHODS: Qualitative analysis of interviews with 11 key informants teaching in population health, medicine, nursing, pharmacy, and optometry training programmes. Transcribed interview recordings were analysed using a general inductive approach. RESULTS: The participants described a range of teaching approaches that they used to increase disability awareness among their students. However, these were largely ad hoc individually driven initiatives reflecting personal interests. Participants identified a critical need to develop and implement a systematic, integrated approach to enhance disability education particularly from a social justice perspective among students in health disciplines. Engaging people with lived experience of disability in teaching and course design, and senior administrative commitment were identified as necessary to address current gaps in education. CONCLUSIONS: In order to develop a health professional workforce competent to respond to the needs of people with disabilities, greater attention is required at a strategic level to enhance the profile of disability education in health curricula. Meaningful engagement of people with disability and senior leadership commitment are critical components that can enable effective progression of this agenda.

Disabled people say 'Nothing about us without us'.

BACKGROUND: This study explored disability community representatives' perspectives on why and how health professional education could be strengthened to address the prevalent challenges in health care experienced by disabled people. METHODS: A total of 14 people from the disability community (disabled people, caregivers and disability advocates) in Auckland, New Zealand, participated in three focus groups moderated by a disabled community researcher. Audiorecordings were transcribed and analysed thematically to characterise broad themes. FINDINGS: Participants described many barriers to health care experienced by disabled people, with service providers' inadequate knowledge of disability issues being a key contributor. Participants viewed educational approaches incorporating disabled peoples' diverse lived realities as critical to improving health system responses to these inequities. They recommended broadening concepts and teaching methods to shift common deficit framing of disability, engaging disabled people to develop and deliver curricula, improving communication, and promoting empathic provider-patient partnerships in care. Study participants strongly advocated inclusive participatory approaches across training pathways using assistive and multimedia technologies that optimise the engagement of disabled people and reduce respondent burden. DISCUSSION: Disability community participants urged strengthening health professional training to address the prevalent inadequacies of health systems in responding to disabled people's needs. They viewed a greater awareness of the lived realities of disabled people and critical consciousness to overcome barriers to care as essential attributes of a competent workforce. These findings indicate the need to engage, empower and work in partnership with disabled people to develop reflexive health professional curricula. Core competencies should be considered mandatory given the increasing prevalence of disability globally. This study explored disability community representatives' perspectives on why and how health professional education could … address … challenges in health care experienced by disabled people.

Removing Barriers and Facilitating Access: Increasing the Number of Physicians With Disabilities.

Nearly one-fifth of the U.S. population has a disability, and many of these Americans experience disparities in the health care they receive. In part, these health care disparities result from a lack of understanding about disability by health care providers. The education of physicians is grounded in a biomedical model that emphasizes pathology, impairment, or dysfunction, rather than a social model of disability that focuses on removing barriers for individuals with disabilities and improving their capabilities. According to a recent report, only 2.7% of medical students disclosed having disabilities-far fewer than the proportion of people with disabilities in the U.S. POPULATION: Including students and other trainees with disabilities-those with lived experiences of disability who can empathize with patients and serve as an example for their peers-in medical education is one mechanism to address the health care disparities faced by individuals with disabilities. At present, medical students and residents with disabilities face structural barriers related to policies and procedures, clinical accommodations, disability and wellness support services, and the physical environment. Additionally, many face cultural barriers related to the overarching attitudes, beliefs, and values prevalent at their medical school. In this Commentary, the authors review the state of disability in medical education and training, summarize key findings from an Association of American Medical Colleges special report on disability, and discuss considerations for medical educators to improve inclusion, including emerging technologies that can enhance access for students with disabilities.