Dr. Little is associate professor in international health and medicine, John A. Burns School of Medicine, Honolulu, Hawaii, and professor of speech at Honolulu Community College.
Correspondence and requests for reprints should be addressed to Dr. Little, International Health and Medicine, John A. Burns School of Medicine, Biomedical Building, 1960 East–West Road, Honolulu, HI 96822.
The article that follows this one discusses the same topic.
To update her article in the June 1999 issue of Academic Medicine, the author addresses the impact of the U.S. Supreme Court's decision in the 2001 Bartlett case on medical students with learning differences. In Bartlett v. the New York State Board of Bar Examiners, the Court ruled that Bartlett was substantially limited in the major life activity of working because of the board's failure to accommodate her reading impairment. The author postulates that the Supreme Court decision in the Bartlett case offers hope to medical students applying for accommodation on medical licensing examinations. If such accommodations are not forthcoming, she suggests that medical schools might ask the question, “Are board examinations a valid measurement of the preparation for the job of a physician?”
* You had a learning difference documented by a nationally recognized authority (33 pages), yet the National Board of Medical Examiners (NBME) denied your application for extended time, stating that you can't have a disability if it wasn't identified in elementary school.
* You appealed the NBME decision with 16 more pages of professional findings, and you were still denied a time extension.
* Your medical school acknowledged your learning difference, gave you time and a half, and, during your four years, you passed all exams but one, which you retook and passed.
* During your clinical year, you passed every rotation and were recommended for honors in three.
* Without accommodation, you failed the United States Medical Licensing Exam (USMLE), Parts 1 and 2.
* Having completed all your medical school coursework, you are currently studying to retake the USMLE exams, a costly expenditure of time and money, in order to graduate.
The “what ifs” above are true, “Moana” is currently over-learning so that her reading rate will no longer keep her from practicing medicine, as I discussed in my earlier article in this journal. She will be a fine physician one day, as her clinical evaluations and medical school examinations attest, but at a high cost. Her situation is not unusual. Nationwide, medical students with learning differences documented in college or medical school are being denied extra time by the NBME.
Dr. Stephan R. Smith of Brown Medical School reported that Brown dropped the requirement that students pass Step 2 of the USMLE to receive their MD degrees. He explained that Brown took this action primarily because the NBME refused to grant extended time to Brown students who were diagnosed with a learning disability by an independent clinical psychologist.2
WHAT IS THE ISSUE?
The issue being raised here (clinical skill versus accommodation on multiple-choice, timed tests) was addressed in a recent commentary in Academic Medicine. Citing 41 references, the authors of “Learning Disabilities and the Meaning of Medical Education” wrote:
The goal of employing compensatory strategies is not to enable otherwise qualified [medical] students to succeed academically. Rather, the goal is to provide accommodations to otherwise qualified [medical] students so that they can become competent and socially committed clinicians.3
Common sense would dictate that a medical student who was rated clinically competent and had fulfilled all the necessary coursework should not be withheld from the practice of medicine by his or her inability to read and analyze quickly. When common sense doesn't prevail and, despite numerous articles, appeals, and speeches, the NBME is unmoved, the law may offer guidance. Guidance attached to monetary punishment is usually more compelling than good advice.
Briefly, the problem of accommodation for learning differences became a legal issue with the passage of the Americans with Disabilities Act (ADA) in 1990. Since then, medical and law students with learning disabilities who believed they had been denied reasonable accommodations on board or bar examinations have complained to the U.S. Attorney General under Title II and III of the ADA, which prohibits public entities from discriminating against qualified individuals by reason of disability. In most cases, students who have appealed under the ADA have lost their cases because the court ruled that they could read at an “average” level, were attending a professional school, and did not have a condition that “substantially” limited a “major life activity.” The ruling in the Bartlett case in the summer of 2001 offers hope to these bright, otherwise qualified, students.4
THE BARTLETT CASE
Marilyn Bartlett was not unlike Moana in that she, too, had finished all her coursework but was prohibited from practicing law because she couldn't pass the bar examination without accommodation. In her case, the Court looked at the clinical evidence and held that Bartlett was substantially limited in the major life activity of reading by her slow reading rate and the fatigue caused by her inability to read with automaticity. Further, the court concluded that Bartlett was substantially limited in the major life activity of working because the board's failure to accommodate her reading impairment was a substantial factor in her failure to pass the bar. Accordingly, the court awarded Bartlett reasonable accommodations (double the allotted time) and compensatory relief.
The Bartlett case offers hope to the many qualified medical students with learning differences who are kept from practicing medicine by their reading rates on timed, multiple-choice tests. In Moana's case, accommodation of time and a half enabled her to pass medical school examinations, including shelf exams. Logic suggests that time accommodation would have the same effect on medical board examinations. This ruling, at the federal level, acknowledges what those who work with medical students have known for years—reading speed and automaticity of response are not sound indicators of a medical knowledge base. In fact, it appears that those who must study hard and over-learn often retain information much better.
Further, this ruling brings to mind a more significant underlying question. Are board examinations a valid measurement of preparation for the job of a physician? In a landmark case in 1971, Griggs v. Duke Power, the Supreme Court ruled that tests that discriminated against minorities and were not shown to have a “manifest relationship to the employment in question” were unconstitutional.5 Although it is not likely that the courts will address the issue of the constitutionality of board examinations, it is inevitable that medical schools will have to examine their validity, as Brown already has.
Finally, there is no doubt that the federal court decision in the Bartlett case offers hope to the medical and law students who learn differently. Most of these students have simple requests—just time and a half on examinations and a quiet room. It is a sad state when the law is the impetus for ethical decision making. Nonetheless, medical students with documented cases of learning differences welcome the fact that law has instituted some common sense. Hopefully, in the future, clinically skilled medical school graduates can practice medicine free of unequal and unwarranted barriers.
1. Little D. Learning disabilities, medical students, and common sense. Acad Med. 1999;74:622–3.
2. Smith S. The USMLE Step 2 should not be a graduation requirement. Acad Physician Scientist. 1999;Sept-Oct:2–3.
3. Hafferty F, Gibson G. Learning disabilities and the meaning of medical education. Acad Med. 2001;76:1027–31.
4. Bartlett v. New York State Board of Law Examiners, No. 93 Civ. 4986 (SS) (2001) [U.S. Dist. Copies may be obtained from the Southern District, New York District Court.]
5. Griggs v. Duke Power, 401 US 424 (1971).