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Academic Medicine:
doi: 10.1097/ACM.0b013e31824dd129
Disabilities Issues

North American Medical Schools’ Experience With and Approaches to the Needs of Students With Physical and Sensory Disabilities

Eickmeyer, Sarah M. MD; Do, Kim D. MD; Kirschner, Kristi L. MD; Curry, Raymond H. MD

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Author Information

Dr. Eickmeyer is assistant professor of physical medicine and rehabilitation, Medical College of Wisconsin and Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. During the conduct of this study, she was a resident, Physical Medicine and Rehabilitation, McGaw Medical Center of Northwestern University/Rehabilitation Institute of Chicago, Chicago, Illinois.

Dr. Do is assistant professor of physical medicine and rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas. During the conduct of this study, she was a resident, Physical Medicine and Rehabilitation, McGaw Medical Center of Northwestern University/Rehabilitation Institute of Chicago, Chicago, Illinois.

Dr. Kirschner is professor of medical humanities and bioethics and of physical medicine and rehabilitation, Northwestern University Feinberg School of Medicine, and attending physician, Schwab Rehabilitation Hospital, Chicago, Illinois.

Dr. Curry is professor of medicine and vice dean for education, Northwestern University Feinberg School of Medicine, and president, McGaw Medical Center of Northwestern University, Chicago, Illinois.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A85.

Correspondence should be addressed to Dr. Curry, Northwestern University Feinberg School of Medicine, 420 East Superior St., Rubloff 12, Chicago, IL 60611; e-mail: rcurry@northwestern.edu.

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Abstract

Purpose: To determine the nature and frequency of impairments and related underlying conditions of medical students with physical and sensory disabilities (PSDs), and to assess medical schools’ use of relevant publications in setting admission criteria and developing appropriate accommodations.

Method: A 25-item survey addressed schools’ experiences with students known to have PSDs and their related policies and practices. The survey instrument was directed to student affairs deans at all 163 accredited American and Canadian medical schools. The authors limited the survey to consideration of PSDs, excluding psychiatric, cognitive, and learning disabilities.

Results: Eighty-six schools (52.8%) responded, representing an estimated 83,327 students enrolled between 2001 and 2010. Of these students, 0.56% had PSDs at matriculation and 0.42% at graduation. Although 81% of respondents were familiar with published guidelines for technical standards, 71% used locally derived institutional guidelines for the admission of disabled applicants. The most commonly reported accommodations for students with PSDs included extra time to complete tasks/exams (n = 62), ramps, lifts, or accessible entrances (n = 43), and dictated/audio-recorded lectures (n = 40). All responding schools required students’ demonstration of physical examination skills; requirements for other technical skills, with or without accommodations, varied considerably.

Conclusions: The matriculation and graduation rates of medical students with PSDs remain low. The most frequent accommodations reported were among those required of any academic or clinical setting by the Americans with Disabilities Act. There is a lack of consensus regarding technical standards for admission, suggesting a need to reexamine this critical issue.

Students with physical and sensory disabilities (PSDs) represent a small proportion of medical school graduates in the United States. As defined by the Americans with Disabilities Act of 1990 (ADA), PSDs are any physical impairment or impairment of special sense organs, including vision and hearing, that substantially limits one or more of a person’s major life activities.1

Several prior studies dating back nearly three decades have shown that approximately 0.2% of medical students graduate with PSDs (range, 0.15%–0.23%).2–5 The precision of these estimates is limited by low survey response rates and various methodological differences, but, even allowing for significant underreporting, they suggest the presence of barriers to medical education for people with disabilities. Compared with population-wide data, these estimates reveal a startling discrepancy. In the 2003 American Community Survey, 6.5% of U.S. citizens aged 18 to 24 reported having a disability, with 2.1% of all respondents classified as having physical impairment and 1.4% having sensory impairment, for an overall PSD prevalence of 3.5%.6 People with PSDs are grossly underrepresented in U.S. medical schools, and their access to a medical education may not have improved during the last 30 years.

This underrepresentation persists despite considerable legislative action and resultant changes in institutional policies. Section 504 of the Rehabilitation Act of 1973 prohibited discrimination against individuals with disabilities who are “otherwise qualified” when seeking admission to a college, university, or other institution of higher learning that receives federal funds.7 Title III of the ADA requires that all public and private institutions provide reasonable accommodations to persons with disabilities. Reasonable accommodation in an educational setting—changes or adjustments that make it possible for an otherwise-qualified student with a disability to meet the requirements of the program—might include environmental modifications such as ramps, lifts, and accessible entrances for a wheelchair user, or auxiliary aids such as audio-recorded lectures for a blind student. Canadian laws are similar, prohibiting discrimination against people with “mental or physical disability” under Section 15 of the Canadian Charter of Rights and Freedoms of 19828 and the Canadian Human Rights Act,9 with the latter document referring to a “duty to accommodate” such persons.

The Association of American Medical Colleges (AAMC) has provided several documents over the years to help medical schools navigate issues involving students with disabilities. In 1979, the Special Advisory Panel on Technical Standards for Medical School Admission identified five categories of necessary abilities and skills: (1) observation, (2) communication, (3) motor, (4) conceptual, integrative, and quantitative, and (5) behavioral and social. The advisory panel did not find trained intermediaries a suitable form of accommodation for students not able to perform these tasks without assistance. For example, they did not find a trained intermediary to be appropriate accommodation for a blind student because “the use of a trained intermediary means that a candidate’s judgment must be mediated by someone else’s power of selection and observation.”10 These expectations were incorporated into the first report of the AAMC Medical School Objectives Project (MSOP),11 Learning Objectives for Medical Student Education: Guidelines for Medical Schools (1998), in which specific skills to be demonstrated by all students are linked to their observations, communication, and motor abilities.

Since passage of the ADA, the AAMC has published four additional handbooks to help schools understand and comply with the new regulations. In 1993, The Disabled Student in Medical School: An Overview of Legal Requirements12 provided an overview of the ADA, and The Americans with Disabilities Act (ADA) and the Disabled Student in Medical School: Guidelines for Medical Schools13 outlined questions to be addressed in developing policies and procedures for admission and promotion of students with disabilities. Medical Students With Disabilities: A Generation of Practice,14 published 12 years later, offers updated legal guidance for medical schools. Most recently, Medical Students With Disabilities: Resources to Enhance Accessibility15 provides practical information on assistive technologies and potential accommodations. Throughout these publications, the AAMC’s definition of technical standards for medical students has remained essentially unchanged since the 1979 Special Advisory Panel report.10

The American Association of Colleges of Osteopathic Medicine (AACOM) Technical Standards Document16 (2009) incorporates the five categories of AAMC’s technical standards but adds the following technical skill requirements: (1) sensory skills, (2) strength and mobility, and (3) participation in osteopathic manipulative medicine laboratory and clinical care encounters. The additional requirements stem from the active participation required to develop “palpatory skills and ability to perform osteopathic treatments.”

Among specialty organizations, only the Association of Academic Physiatrists has published disability-related guidelines applicable to general medical education.17 These guidelines promote the inclusion of a diverse population of students with PSDs, starting with the five categories of technical skills from the 1979 AAMC report but further emphasizing the importance of reasonable accommodations to gain technical skills, career counseling, and the appropriateness of the use of trained intermediaries: “the candidate who cannot perform these activities independently should be able, at least, to understand and direct the methodology involved in such activities.”17

Many have questioned the emphasis placed on specific physical and sensory capabilities in defining the technical skills required by medical schools. Reichgott18 considered the relative importance of technical skills to other requirements of graduates, including intelligence, professional attitude, and ability to effectively interact and communicate. VanMatre and colleagues19 surveyed students, residents, and faculty at a major academic health center and found that respondents deemed skills used in interpretation and observation more important than purely motor skills used for technical procedures, such as auscultation, palpation, or insertion of an intravenous catheter.

Beyond any inability to satisfy technical skills requirements, other reported barriers to medical education for students with PSDs include paternalistic attitudes, medical schools’ inexperience in providing reasonable accommodations, and lack of career counseling when choosing a specialty for residency.20,21 Others have noted the value of including students with disabilities in the medical school environment, including the potential insights these students can offer to address barriers often compromising health care for people with disabilities.19,22

The present study’s objectives were to further describe the frequency and types of impairments and underlying conditions of medical students with PSDs, medical schools’ prevailing approaches to reasonable accommodation, and the extent to which previous AAMC and AACOM guidance has been useful to schools regarding students with PSDs, particularly concerning reasonable accommodations for required technical standards.

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Method

We sought to ascertain the experience and practices related to students with PSDs of all Liaison Committee on Medical Education (LCME)-accredited and American Osteopathic Association (AOA)-accredited schools, granting the MD and DO degrees, respectively, in the United States and Canada. To do so, we administered a 25-item instrument (Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A85) consisting of multiple-choice and open-ended questions addressing the schools’ experiences with students with known PSDs. Respondents were asked to quantify the number of students with PSD admitted and graduated, the nature of the impairments and disabilities these students experienced, and their school’s related policies and practices, including institutional resources for support and the types of accommodations provided. We explicitly excluded mental health, cognitive, and learning disabilities from the instrument because these generally raise issues of academic accommodation, whereas PSDs involve interaction with the physical environment. We piloted the survey with a sample of practicing physicians with PSDs and academic deans, and a draft was critically reviewed by the National Committee on Student Affairs of the AAMC Group on Student Affairs (GSA). The Northwestern University institutional review board reviewed and approved the study protocol.

The survey was then administered to LCME-accredited schools via a GSA listserv of student affairs deans and to AOA-accredited schools through a similar listserv maintained by the AACOM. A cover letter explained the purpose of the study and included definitions of terms used in the survey items. The cover letter also asked that only one respondent per accredited institution participate (in most instances, only one dean per school was included on the listserv) and included a hyperlinked URL to access the Web-based survey. The survey was anonymous and did not provide any school-specific demographic information. The questions were identical for both groups of schools, except that the instrument for AOA-accredited schools included AACOM publications as a response option for the question regarding the source of their technical standards. The Web link was open for two months in the fall of 2010 for the LCME-accredited schools and for one month in the spring of 2011 for the AOA-accredited schools. We sent periodic reminders via each listserv while the surveys were open.

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Participants

Potential respondent schools included those (1) accredited or provisionally accredited by the LCME or AOA, (2) accepting students as of fall 2010, and (3) represented by at least one active address on the listservs used in the study. One hundred thirty-four LCME-accredited schools and 29 AOA-accredited schools met these criteria, for a total potential sample of 163 schools.

One item in the survey asked the respondent to specify the number of years, up to a maximum period of 10 years (i.e., dating back as far as 2001), for which he or she was able to report the school’s experience. Another item recorded the school’s current total enrollment. We used these items to estimate the total number of students present during the years of the responding deans’ experience by dividing each current total enrollment figure by four (approximating the size of each annual cohort), multiplying by the duration in years of that respondent’s experience, and summing the results.

We analyzed all data using Fisher exact test, chi-square test, or independent t test as appropriate, using the VassarStats (Vassar College, Poughkeepsie, New York) Web-based platform.

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Results

Summary of combined data from LCME- and AOA-accredited schools

Eighty-six of the 163 (52.8%) schools responded—70 of 134 (52.2%) LCME-accredited schools and 16 of 29 (55.2%) AOA-accredited schools. Forty-five of the 86 responding (52.3%) were public schools, and 41 (47.7%) were private schools. Sixty-five of the 86 schools (75.6%) were in a university setting, and 35 (40.7%) were freestanding institutions. The individuals responding to the survey reported a mean of 6.5 years of experience (median, 6 years). Multiplying each respondent’s years of experience by the reported class size at his or her institution, as described above, yielded an estimate for the number of students enrolled by the respondent schools between 2001 and 2010 of 69,547 MD students and 14,780 DO students (84,327 total). Among these were 470 who matriculated with PSDs (0.56% of the estimated total) and 356 students with PSDs (0.42%) who had graduated (Table 1).

Table 1
Table 1
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Among the 86 respondents, 70 (81.4%) were familiar with the AAMC’s Medical Students With Disabilities: A Generation of Practice.14 However, only 16 schools (18.6%) used the 1998 MSOP learning objectives11 in generating their published technical standards for the admission of disabled applicants. Sixty-one schools (70.9%) used guidelines derived within their institution, and only five of the 16 DO-granting schools (31.2%) used the AACOM Technical Standards Document.16 Respondents reported technical standards guidelines having last been revised before or during 2005 at 33 schools (38.4%), after 2005 at 36 schools (41.8%), and did not know the date of origin at 9 schools (10.5%).

Of the 470 students with PSDs who matriculated at the participating schools, the most commonly reported impairments or limitations to activity were difficulty with hearing (for 86 students), ambulation (64 students), and vision (60 students); these three categories accounted for 44.7% of students with PSD (Table 2). The most common underlying conditions for the reported impairments and limitations were hearing impairment/deafness for 83 students, low vision/blindness for 52 students, spinal cord injury for 23 students, and brain injury for 21 students (Table 3). The most commonly reported accommodations for students with PSDs were extra time to complete tasks or exams for 62 students; ramps, lifts, or other accessible entrances for 43 students; and dictated or audio-recorded lectures for 40 students (Figure 1). Samples of participants’ open-ended responses to an item requesting additional thoughts about providing accommodations for students with disabilities can be found in List 1.

Table 2
Table 2
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Table 3
Table 3
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Figure 1
Figure 1
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Regarding required technical skills, each of the 74 schools responding to this item required physical examination skills (36 with and 38 without accommodations), and 70 of these 74 schools required basic life support skills (30 with and 40 without accommodations). Other expectations for technical skills varied, with central line placement and lumbar puncture required by fewer than half the schools, and others (suturing/knot tying, Foley catheter placement) required by a substantial majority (Figure 2).

Figure 2
Figure 2
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Comparison of responses from LCME- and AOA-accredited schools

There were no statistically significant differences between response rates from the LCME-accredited and AOA-accredited schools, in the academic setting of the schools (i.e., university-based versus freestanding), or in the mean number of years of the respondents’ experience in student affairs or similar administrative positions. LCME-accredited schools had a higher percentage of matriculating students with PSDs compared with AOA-accredited schools (426/69,547 [0.61%] versus 44/14,750 [0.29%]; P < .0001). In both sets of schools, the number of students with PSDs graduating during the study period was considerably lower than the number matriculating (ratio of graduating students to matriculating students: 0.77 for LCME-accredited schools versus 0.66 for AOA-accredited schools; not significant).

Difficulty with hearing and vision were commonly reported impairments at both LCME-accredited and AOA-accredited schools. LCME-accredited schools reported more students with difficulty ambulating than did AOA-accredited schools (61/426 [14.3%] versus 3/44 [6.8%] of students with PSDs; P < .05). The other reported impairments and underlying conditions were comparable between schools. Patterns of accommodation were also similar between the groups of schools.

Regarding required technical skills, complete physical exam skills and basic life support were the most commonly required skills for both sets of schools. However, all responding AOA-accredited schools also required suturing and knot tying as well as removing staples, sutures, and drains. LCME-accredited schools varied in their requirements for these two skills.

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Discussion

These results show that, since 2001, 0.56% of medical students matriculating and 0.42% of those graduating have had a PSD known to their school administrations. These proportions are somewhat higher than those found in previous studies,2–5 though in absolute numbers the differences are small. The proportions of students with PSDs still fall well below the proportion of the general population aged 18 to 24 with similar disabilities (3.5%).5 At the rates found in the present study, the students with PSD entering the nation’s MD- and DO-granting schools in 2010 would number fewer than 140.

The present data can only suggest whether students with disabilities succeed in medical school at a rate commensurate with that of their nondisabled peers. The matriculating and graduating students reported by a given respondent are not drawn from the same class cohorts—some of the matriculating students, admitted during the last three years, were still enrolled at the time of the study, and some of the graduating students matriculated before the respondents were in their present positions. To the extent that these students did not matriculate evenly through time, or if some students acquired their disability while in medical school, the rates of matriculation and graduation might well differ from what we report. Still, given that 96% of students matriculating at MD-granting schools in the United States graduate within 10 years,23 the ratio of graduating-to-matriculating MD students with PSDs in this study (76.8%) suggests an unusually high attrition rate. The comparable ratio at DO-granting schools (65.9%) is even lower, though it is based on fewer students and does not represent a statistically significant difference from the MD student result, and is perhaps commensurate with higher overall cumulative attrition rates of approximately 9% at DO-granting schools.24 There could be many reasons underlying a high attrition rate for students with PSDs, including difficulties obtaining necessary accommodations, attitudinal barriers among faculty or peers, or a student’s inability to demonstrate requisite core competencies despite the school’s attempts at accommodation. It is also possible that a student whose impairment progresses during enrollment, or one who acquires a more in-depth understanding of the demands of the profession, may elect to pursue other options. A longitudinal study of matriculating students with disabilities is needed to better understand the reasons underlying these lower apparent graduation rates and to improve our understanding of the supports and accommodations needed to facilitate the success of students with PSDs.

However rare it may be for a student with a PSD to graduate from medical school, it is clearly not so rare for a physician to experience disability in the course of his or her career. In their recent review of disabilities among the physician workforce, DeLisa and Thomas22 estimated that people with disabilities make up 20% of the population, 2% to 10% of practicing physicians, and <1% of medical school graduates. Those physicians acquiring PSDs after training have the advantages of established professional standing and experience that likely facilitate acceptance of their requests for physical accommodations or other modifications of their work life and that lead to adaptations better tailored to their discipline-specific needs.

List 1

Sample of Open-Ended Responses From a Survey of 70 Liaison Committee on Medical Education–Accredited and 16 American Osteopathic Association– Accredited Medical Schools, 2010 and 2011

Please share any additional thoughts you have about providing accommodations for students with disabilities:

“We will go out of our way to provide reasonable accommodations for students with disabilities as long as they can do what all students are expected to do with accommodations.”

“We need to realize that you cannot accommodate everything. Surgeons need to be able to use their hands, and students who cannot need to be directed into different specialties like psychiatry or radiology.”

“It is our view, as an institution, that students should perform all those functions that they may be required to perform as an intern, irrespective of specialty, and that we have a responsibility to provide reasonable accommodations to help them do so. If they can’t do it [with or without accommodations], they don’t graduate.”

“We have had students with pretty profound hearing and visual loss, profound weakness, and one student who was paraplegic. Our technical standards do not allow the use of a trained intermediary, but in spite of this, we have never had a student we couldn’t work with to complete our requirements. In looking at our outcome-oriented technical standards, it is hard to see how someone who was totally blind or a total quadriplegic could complete the requirements. Anything short of that seems possible.”

“The number of students ‘announcing’ their disabilities after they have experienced academic difficulty presents an appearance of gaming a system in many instances.”

“We have made exceptions to our technical standards to allow students to graduate. Most of our students with disabilities have, despite major physical limitations, been very high functioning and been able to adapt and we have been able to accommodate reasonably well. Having said that, one of the most difficult aspects is career counseling and residency application for students with disabilities. What should be disclosed via ERAS [Electronic Residency Application Service] application in personal statement? MSPE [Medical Student Performance Evaluation] letter? Some of our students with disabilities have had a difficult time matching despite being bright and highly motivated students.”

It also seems that a student with disability, not yet exposed to the particular demands of various clinical settings, would be at a disadvantage to anticipate his or her needs for accommodation, or even know what the physical requirements of practice will be. A detailed study of the work lives and accommodations made by physicians with disabilities who are successful in practice would provide much needed insight for disability accommodation officers, student affairs deans, and future students with disabilities. A network of peer support of such physicians who could provide real-time problem solving and career counseling could be an invaluable asset as well.

Concerns about the costs of accommodations and the rigor of medical training are frequently cited as rationale for excluding students with PSDs from the profession.20,22 In our study, sensory impairments (of hearing and vision) and limited ambulation were the most commonly reported disabilities among medical students. The most common types of accommodation for these disabilities reported by the student affairs deans ranged from extra time to complete tasks or exams, access to dictated or audio-recorded lectures, and physical modifications such as ramps, lifts, or other accessible entrances. These accommodations are no different from those required of any academic setting, as mandated by the ADA, and, as such, the capacity to address them should already be present. Moreover, flexibility in scheduling and multiple modes for information processing are increasingly achievable in today’s technology-rich environment. Indeed, better incorporation of students with disabilities into the medical school environment, particularly clinical environments, could provide insights that help address the barriers often compromising health care for people with disabilities.25 As one survey respondent stated:

Our students with physical and sensory disabilities have taught us a lot about the creativity of people with disabilities and about the technology that exists to enable them to succeed in accomplishing our curriculum. Their presence has really effected a positive change in faculty attitudes about accepting and teaching students with disabilities.

The more difficult questions surrounding the medical education of students with PSDs involve the technical standards established by the profession to ensure physicians’ comprehensive and safe care of patients, and the nature of “reasonable accommodations.” Among all responding medical schools in our study, the two technical skills most consistently required, with or without accommodation, for graduation were physical exam skills and basic life support. The DO-granting schools all required additional physical technical skills, such as suturing, knot tying, and removing staples, sutures, and drains, often offering the option of accommodation. With regard to the frequency of various accommodation requests, the accommodations least likely to be provided for students with PSDs were assistance for observation, assistance for physical exam skills, and excuse from on-call responsibilities (Figure 1), likely reflecting the inadmissibility of these accommodations under the schools’ prevailing technical skills requirements.

The schools’ technical skills requirements seem to have been informed by the various AAMC or AACOM guidelines, as most respondents were familiar with them, but nearly three-quarters of responding schools had developed school-specific standards. This suggests a lack of consensus about the technical skills required of all physicians and about the types of accommodations that are “reasonable” within the bounds of professional roles and responsibilities. These are issues deserving of further attention, particularly in light of the changing practices, tools, and technologies of medicine. The performance of basic CPR or suturing of a wound, which are among the procedural skills often required by respondent schools, are simply not critical to the work of many physicians. At the medical school level—prior to residency training, where physical technical skills are undoubtedly of much greater importance for certain specialties—the crucial elements of physician competency are most reliant on a broad knowledge base, a patient-centered perspective, and the cognitive skills of assessment and decision making. Even in settings with a more procedural orientation, many physicians now work with midlevel providers and direct these providers’ performance of certain tasks, or rely on “complex procedure” teams for central venous access, bone marrow aspirates, and the like.

It is time to revise medical schools’ technical standards such that they become less of a barrier to admission of students with PSDs and, instead, facilitate the appropriate inclusion of this group of people who are substantially underrepresented in medicine. The ADA Amendments Act of 2008 provides new impetus for medical schools to engage in the “substantive reflection on the ultimate relationship of medical education to the practice of the profession of medicine”25 and to revisit the role of admissions committees and curriculum leaders in articulating essential competencies and reasonable accommodations policies.26,27 A recent change in the accreditation standards of the LCME to require “technical standards for the admission, retention, and graduation of applicants or students with disabilities” in place of the previous focus on standards for admission alone may also help stimulate this work.28 The result can be a more diverse profession, as cognizant of the human vulnerabilities of its own members as it is of those of the patients it serves, and arguably more effective in understanding and addressing those patients’ needs.

Acknowledgments: The authors wish to thank the Group on Student Affairs National Committee on Student Affairs of the Association of American Medical Colleges, and the staff of the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine, for their assistance with review and distribution of the survey. They appreciate the assistance of Anne Deutsch, PhD, with statistical analysis, and thank James Sliwa, DO, Lisa Iezzoni, MD, MSc, and Melanie Rak, MD, for their helpful input in the development of the survey.

Funding/Support: None.

Other disclosures: None.

Ethical approval: This study was approved by the Northwestern University institutional review board.

Previous presentations: Presented in part at the annual meeting of the Association for Academic Physiatry, Chandler, Arizona, April 14, 2011.

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References

1. Americans with Disabilities Act of 1990. PL 101–336. Approved July 26, 1990 (104 Stat 327)

2. Moutsiakis D, Polisoto T. Reassessing physical disability among graduating US medical students. Am J Phys Med Rehabil. 2010;89:923–930

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5. Yarnell SK. World Institute on Disability, June 30, 2011 Berkeley, Calif Personal communication with RH Curry

6. Weathers RR. A Guide to Disability Statistics From the American Community Survey. 2005. Ithaca, NY Cornell University

7. Rehabilitation Act of 1973. PL 93–112. Approved September 26, 1973 (87 Stat 355)

8. Canadian Charter of Rights and Freedoms, R. S. C. 1985 Appendix II, No. 44 see also Part I (ss. 1 to 34) of the Constitution Act, 1982

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24. Association of Colleges of Osteopathic Medicine.. 2003–2004 to 2009–2010 Osteopathic Medical School Attrition Summary. http://www.aacom.org/data/Documents/2011-COM-Attrition-Summary.pdf Accessed January 19, 2012

25. Kirschner KL, Breslin ML, Iezzoni LI. Structural impairments that limit access to care for people with disabilities. JAMA. 2007;297:1121–1125

26. Smith WT, Allen WA. Implications of the 2008 amendments to the Americans with Disabilities Act for medical education. Acad Med. 2011;86:768–772

27. DeLisa J, Silverstein R, Thomas P. More implications of the 2008 amendments to the Americans with Disabilities Act: Influencing institutional policies, practices and procedures. Acad Med. 2011;86:677–679

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