Issues of identity and identification are highly contested aspects of social life, and the case of disability is no exception. The act of establishing one's identity as a person with a disability,1 or the dynamics of rejecting such an attribution, can be volatile points of social action, both within the disability community and between that community and society at large. The recent newspaper reports of former Miss America Heather Whitestone's decision to have a cochlear implant…“in the hope of entering the ‘real world’” is one of innumerable examples.2 Even the seemingly innocuous phrase “disability community,” or a stated preference for the term “learning differences” over “learning disabilities,” or for “differently abled” instead of “disabled,” functions more as a political claim than as an innocent terminological difference. Here, too, we can encounter issues of status and hierarchy, including the legitimacy of “voice” and the claimed (or accorded) “right” of an individual to speak about issues of disability (or of race, social class, or gender for that matter), on one's own behalf or on behalf of those who identify themselves as members of a particular group. What “outsiders” see as homogeneous or “undifferentiated” quickly mutates into highly nuanced shadings of status, legitimacy, and power as our frame of reference shifts from periphery to center. In the movie School Daze, light- and dark-skinned African Americans clashed because they held disparate dreams of assimilation and status.3 The fact that Spike Lee made this film and not, for example, Ron Howard is neither accidental nor incidental.4 Individuals with mobility impairments may freely sprinkle their conversations with terms such as “gimp” and “crip,” while “normals,”5 or even those with other impairments such as visual or hearing, would find their use of these terms to be inappropriate or otherwise forbidden. Phrases such as “black pride” and “deaf power” function as points of identity in the social and political lives of marginalized people. These “identity markers” generate considerable unease among outsiders, and nowhere is this more the case than with disability. For those of us who are outsiders, persons with disabilities represent a future self, a disconcerting reminder that the present truly is a time of waiting-to-be-disabled.
With the above as background, we find it both a conceptual challenge and a source of personal disquietude,6 to revisit the topic of learning disabilities (LDs) and medical education.7 From a structural functionalist perspective, LDs exist as points of disequilibrium and deviance within the broader social system, as they function to establish boundaries between what a society defines as “normal” and “not-normal.”8 From this vantage point, it should not be surprising (even if distressing) to find individuals with physical and/or cognitive impairments being the objects of critical social commentary because of their efforts to move beyond social stigma and workplace discrimination.9,10 The oft-contested nature of LDs (who is and isn't, who can and can't be, with what import and to what ends?), along with the authors' own lived experiences,6 allows for what we hope is an informed examination of LDs and medical education. In the following pages, we organize our observations around two points of reference. First, we examine the arguments raised in the preceding paper by Professor Little11 in her synopsis of Bartlett v New York State Board of Law Examiners 12 (with its focus on legal training, professional certification, and dyslexia). In the same context, we also focus on the pseudonymous “Moana,” who functions for Little as a bridge between the particulars of Bartlett and what Little views as the analogous realms of medical education, medical licensure, and LDs.
Second, we use the fundamentally social nature of disabilities (the more accurate term is “handicaps”13) to raise several issues about medical education and medical work, including the status of medical schools as social institutions charged with the responsibility of transforming lay neophytes into physician-professionals. To this end, we refer briefly to the professions literature to explore how medicine's status as a profession involves special obligations to society at large. Some of the points we raise owe their origin to astute arguments raised by Little. Others are of our own making, including some we consider analytically suspect and/or immoderate. Nonetheless, it is our intent to be provocative, and thus we expect to raise possibly unsettling questions about possible points of tension between LDs and medical education. Generally, we avoid making legal claims or drawing legal conclusions. As will become explicit in a moment, we share some of Little's convictions regarding the applicability of Bartlett to the arena of medical education and LDs. However, we feel neither competent nor inclined to draw conclusions about Bartlett as “good case law” or as “precedent-setting.”14
THE BARTLETT CASE
The legal clash between Marilyn J. Bartlett and New York State Board of Law Examiners is more than one trial or a single set of judicial findings. Dating back to 1993, there have been six different trials, including an appeal to the U.S. Supreme Court and two appearances before the 2nd U.S. Circuit Court of Appeals.15 The Bartlett decision referred to in Little's paper12 is number six in what could be a still-evolving chain.
We agree with Little that some of the decisions handed down in “Bartlett VI” have important implications for medical education.16 We also believe that the legal decisions reached across these six trials have broken new ground in terms of how one should define (legally) the presence (or absence) of LDs and how one should frame comparisons between an individual with an LD and “most other people” (the necessary comparison group set by the Americans with Disabilities Act [ADA] and Section 504 of the Rehabilitation Act of 1973 [Public Law 93–112]). At the same time, we see aspects of Bartlett VI that lead us to believe that this court decision may leave a more narrow legacy than otherwise predicted by Little.
Overall, the picture that emerges from Bartlett VI is rather positive with respect to LDs and licensure. Burdened with a documented “learning difference”17 and buffered by a lifetime of struggles with an LD (dyslexia), Marilyn Bartlett was denied accommodations by the New York State Board of Law Examiners. She sued and over several court challenges was awarded “injunctive relief in the form of reasonable accommodations on the bar exam…along with monetary damages…for each of the five bar examinations that she had taken.”12, p.3 The court also found Marilyn Bartlett to be a “person of high integrity”12, p.34 as well as someone who is “bright,” “articulate,” and “hardworking.”12, p.30,31 The Court noted that she was a law school graduate (“albeit with only mediocre grades”) and that she had received “excellent job performance reviews” where she worked as a legal associate. Based on these and related determinations, Judge Sonia Sotomayor concluded: “I believe she has sufficient knowledge of the law to pass the bar…” and thus, the Board's denial of accommodations “was a significant factor in her failure to pass the bar exam.”12, p.36 In addition, the Court found that:
- Test scores from psychometric measures are not sufficient to establish the presence or absence of an LD. Instead, “clinical observations,” “behavioral observations,” and/or “clinical judgment” are “essential to a diagnosis of LD.” A proper evaluation must look at the behaviors the individual uses when taking the test.12, pp. 6,18,19,23,24
- “Clinical judgments are objective (albeit qualitative).”12, p. 24
- One must “consider the existence of a disability on a case-by-case basis.”12, p. 25
- The bar exam “functions like an employment examination” for a “class of jobs” (lawyering).12, p. 34
- The board's decision to deny accommodations to Bartlett was “driven, at least in part, by misperceptions and stereotypes about learning disabilities.”12, p. 33
- And finally,
- The U.S. Supreme Court had established, through a series of rulings,18 critical distinctions between “mitigating measures” that “merely assist” one's functioning (e.g., devices that allow an individual to remain functional, such as a wheelchair for someone with a mobility impairment or lip-reading for someone who is deaf) versus “corrective devices” or “adaptations” that directly impact on, or alter, the status of the impairment (e.g., corrective lenses).12, p. 26
In short, and drawing upon the above-referenced Supreme Court rulings, Judge Sotomayor concluded that the plaintiff's need to have her e-mails and other text-based materials read to her, and her use of other adaptive strategies to cope with and understand printed materials (e.g., study groups), were strategies/aids that “merely assist[ed]” her functioning and did not directly have an impact on the underlying LD.
What import does all of this have for professor Little's Moana, whose request for accommodations has been denied by the National Board of Medical Examiners (NBME)? Is Bartlett “the answer,” or is Judge Sotomayor's decision fundamentally more consistent with the particulars of legal rather than medical work? We believe that the answer (or answers) is highly dependent on what parts of the Bartlett VI one wishes to highlight.
A Test Is a Test Is a Test
One of the core points revisited several times by Judge Sotomayor in her decision is that a diagnosis of LD, even when it is authenticated by extensive documentation, and with that doocumentation prepared by a “nationally recognized authority” (reflecting phrasings used by Little), does not mean that the individual is disabled under the ADA and/or Section 504. Moana, for example, could have a documented LD and not be “substantially limited in the major life activities.” Furthermore, Moana could have received accommodations while in medical school, and yet have that decision (by her medical school) be irrelevant to the fundamental legal issue of whether she has an LD under the ADA and/or Section 504. Furthermore, even a finding that Moana had the same “learning difference” as Marilyn Bartlett (i.e., “dyslexia”), would not preemptively establish that Moana has an LD under the ADA and/or Section 504.19 This lack of “blanket generalizability” is one of the reasons why courts consistently have noted that they must “consider the existence of a disability on a case-by-case basis.” Finally, establishing that an individual is “qualified” under the ADA is something that must be done before the court can begin to assess what might or might not be “reasonable accommodations,” or how those accommodations might or might not “fundamentally alter” (in this case) the training program.
On a positive note (for Moana), the Court found that test scores are not sufficient to establish the presence—or absence—of an LD. Although Bartlett still was compared with the “average person in the general population” (as required by law), the comparison was grounded in the actual work of reading rather than in outcome measures such as reading comprehension or diagnostic test scores. In Bartlett VI, the Court determined that the effort exerted by Marilyn Bartlett to understand written materials was considerable, and the exhaustion she experienced in doing so greatly exceeded anything required of “most people” while reading. By approaching LDs in this way, the court ruled that clinical assessments drawn from an individual's “lived” efforts to cope with and work through the disability in question are essential to establishing a diagnosis of LD and are more germane than stand-alone diagnostic or “performance” test scores. Furthermore, and in direct conflict with a position argued by the defense (the NBME), the court ruled that these clinical judgments are “objective” data. So, how does Moana fare in these respects? Actually, quite well. The fact that she has been admitted to a medical school will not be “held against her.” Similarly, the fact that she most likely has average scores on reading comprehension and other diagnostic tests will not be a blow to her “case” since what will be examined is not her test scores relative to “most people,” but rather the actual difficulties she has processing information. Score: +1 for Moana.
“Assisting” versus “Altering”
The picture becomes more ambiguous when we examine how the court used the trilogy of Supreme Court decisions cited above to differentiate between adaptations that “merely assist” and those that directly have an impact on, or alter, the disability in question—including “subconscious adjustments.” Based upon Marilyn Bartlett's clinical evaluations and her lived history with dyslexia, the court determined that the strategies Bartlett employed were “adaptive.” But, the court might not be so inclined in Moana's case, and were a court to rule that some of Moana's strategies (including psychological adaptations) fundamentally altered her disability, then that Court (we believe) would have to focus more on outcome measures such as diagnostic and achievement test scores rather than on clinically-based information about the “work” of reading. How might Moana fare in these overall assessments? The answer is neither clear nor predetermined. Score “0” points for Moana.
“Otherwise Qualified” and “Otherwise Able”
Perhaps of greatest relevance to Moana is how Judge Sotomayor determined that Marilyn Bartlett was “otherwise qualified” to take the bar exam and, second, that she would have been able to pass the exam except for the NBME's denial of accommodation. In establishing “otherwise qualified,” a court wishes to know whether the plaintiff has met all the prerequisites or requirements for licensure, except for “X”—in this case, passing the bar exam. Determining what might be considered “otherwise qualified” calls for information about previously established facts or about procedure and/or protocol. Were the proper course prerequisites taken and passed? Was a necessary residency requirement satisfied? Did “A” happen before “B?” Generally, this kind of assessment is relatively straightforward, even when the issue involves determining “equivalents.” (e.g., Can a requirement for an “upper-level mathematics course” be satisfied by a course in “biostatistics?”)
The picture becomes more sibylline when we address the issue of “otherwise able.” Here, we must consider performance criteria such as the “technical standards” used by medical schools during their admission processes (see below). Applicants must attest that they can meet the physical and cognitive demands of the training program (and/or the work requirements for which that training stands as preparation). Establishing whether standards have been (or can be) met is not easily determined. If Moana took the test without accommodations and passed, then our legal question is moot. If she took the test minus accommodations, failed, requested accommodations and then was refused, we would have our litigant…and if she prevailed legally and was provided with court-ordered accommodations, and passed, then— and only then—would we have our measure of proof. The problem is that this proof is ex post facto and is not the kind of proof needed by the court—namely “proof” that can be determined before the fact in question (e.g., before the board exam is taken). In Bartlett VI, although Judge Sotomayor did acknowledge that “there is no real way” to determine “whether plaintiff has sufficient domain-specific knowledge to pass the bar exam,”14, p.35 she promptly concluded 14, p.36 that the Law Association's refusal to provide accommodations “was a significant factor in her failure to pass the bar exam.” On what basis did the judge reach this conclusion? As noted above, the Court cited Bartlett's employment as a legal associate, her “excellent job performance reviews,” and the favorable impression she made on the Court in her role as a persistent and diligent litigant. In short, the Court drew upon her work experience and her “presentation of self” (to use another sociological term) during her litigations (dating back to 1993). The Court had no direct “proof” that Bartlett would pass the bar exam sans accommodations. Instead, it drew an inference.
How might all of this apply to Moana? First and foremost, it seems to us that Moana, could she start over, would need to establish her medical credentials, just as Marilyn Bartlett established her legal capabilities. In other words, Moana would need to become employed as a physician assistant, a nurse practitioner, or perhaps a physical therapist or RN (LPN may be stretching the chain of inference too far).20 She also would need great performance reviews. Moana should not have planned to attend medical school right out of college. She needed time to establish a record of “acceptance” and of “accepted functioning” (both are our terms) prior to becoming a litigant. How does Moana fare in these respects? Not very well, for none of these conditions has been stipulated in Moana's case. Moreover, few individuals— learning disabled or not—apply to medical school with these types of prior work experiences: Score −1, or perhaps even −2, for Moana.
The inferred nature of “otherwise able” hints at another problem as well, one that is more conceptual, and is grounded in the qualifier “otherwise.” Being able to meet a school's curricular standards, except for problems associated with, for example, a mobility impairment, seems more “clear-cut” (to us) than ascertaining whether one can process information well enough to diagnose and treat patients, except for a LD. Medicine is an occupation whose “professional” identity is grounded in its socially established and legally affirmed right to exercise discretionary decision making. Issues of autonomy and dominance, (namely, control over one's own work and the decision making of others who work in the same occupational arena, such as nurses or lab technicians) are seminal to medicine's status as a profession. While the public is expected (as a social norm) to seek out physicians when they are sick, that same public expects that physicians are able to draw together disparate pieces of information (results of lab tests, information provided by the patient, the patient's physical appearance, etc.) and meld those pieces into a coherent picture that will guide future diagnostic efforts and treatment. This is what doctors “do,” and they are supposed to do all of this mental processing at an exceedingly high level of competence. Thus, we are at a loss to imagine how a physician is “otherwise able” to diagnose and treat disease when the mental/cognitive processes that appear so fundamental to the work of doctoring (thinking, organizing, manipulating, or synthesizing information) are impaired in some way. We readily confess to the reader that we are quite stymied at this point. We can imagine “ways around” mobility impairments for example, but we cannot imagine “ways around” the cognitive processing of information.
TECHNICAL STANDARDS AND THE UNDIFFERENTIATED MEDICAL STUDENT
The difficulties associated with establishing whether a medical student with a disability is “otherwise able” bring us to a ubiquitous, yet infrequently referenced, aspect of medical education, namely, the technical standards that underlie admission and matriculation. The fact that all medical schools technically possess such standards to address whether their students are able to perform the cognitive, technical, and professional responsibilities of their medical schooling (and, possibly, subsequent medical work) is of great relevance to the issue of LDs and medical education. The fact that the medical education literature rarely refers to these standards21 makes them all the more intriguing, and thus worthy of a brief review of their structure and content.
Of particular relevance to Bartlett (along with the case of LDs in general) is the fact that these standards specifically address issues of cognitive functioning (see below). In this respect, many of these standards include term-specific language indicating that the school considers the MD certification to be an “undifferentiated degree.” Below is a segment of one school's technical standard that speaks to this issue.
Because the MD degree signifies that the holder is a physician prepared for entry into the practice of medicine within a graduate training program, the recipient must have the knowledge and skills to function in a broad variety of clinical situations and to render a wide spectrum of patient care as required by the curriculum. Our Mission Statement, goals, and objectives are supported by the 1979 recommendations of the Association of American Medical Colleges Special Advisory Panel on Technical Standards for medical school admission that state, in part, that the M.D. degree is, and must remain, a broad, undifferentiated degree attesting to the acquisition of general knowledge in all fields of medicine and the basic skills requisite for the practice of medicine.22
This second example makes this same point, albeit more succinctly.
The MD degree signifies that its holder is a physician prepared for entry into the practice of medicine within postgraduate training programs of diverse types. The M.D. degree is, and must remain, a broad undifferentiated degree attesting to the mastery of general knowledge in all fields requisite for the practice of medicine.23
The rub in all of this is that while medical students receive what organized medicine considers an “undifferentiated training” leading to an “undifferentiated degree,” students do not go on to practice an “undifferentiated medicine.” Virtually all medical students finalize their specialty and residency program decisions long before graduation and thus function for an appreciable part of their training as, for example, pre-pediatric or pre-cardiology students, even though significant parts of their training have nothing to do with cardiology or pediatrics. Even if a student goes on to practice “primary care medicine,” his or her practice still will be restricted in some fashion, as when a family practitioner decides not to do obstetrics or routinely refers athletic injuries to an orthopedic surgeon.
The difference between training and clinical practice is seminal to those who argue for a more inclusive approach to applicants with LDs (or disabilities generally). For these advocates, impairments are “incidental differences” rather than “determining handicaps.” Furthermore, proponents note (correctly) that there are physicians with all kinds of disabilities, including LDs. These physicians, the argument continues, stand as lived proof to the abilities that can be wrought by individual perseverance and courage. Thus, we read about (and admire) the “world-famous” and “pioneering” pediatric neurosurgeon Fred Epstein (of New York's Beth Israel Medical Center North), who has an LD and was turned down by every medical school he applied to (his eventual degree came from New York Medical College). We also see abilities rather than dis-abilities when we read about James Post, a quadriplegic since age 14, who was rejected by ten medical schools “despite an outstanding academic record and a life-long desire to become a physician.” Eventually accepted by Yeshiva University's Albert Einstein College of Medicine, Post graduated with honors.24 There are hundreds of other examples, along with professional societies to represent the interests of physicians with disabilities.25 Nonetheless, it also is true that many of these physicians do not practice clinical medicine, or if they do, practice in highly circumscribed ways, thus straining the applicability of the word “difference” to satisfactorily represent these complicated states of affairs.
A parallel argument for inclusion follows the logic embedded in Little's use of the phrase “learning differences.” We are all, the argument runs, “differently abled.” Each of us has different abilities and dis-abilities. An oncologist friend once worded this argument as follows; “I can't be a surgeon. I can't do it. I don't have the manual dexterity or the mind-set.” As much as I understand the point he was trying to make, my friend is not a person with a disability; not in his own eyes, not in the eyes of his employer, and not in the “eyes” (we feel certain) of the ADA. Nor would this oncologist be forced to “fess-up” upon reading his school's technical standards (leaving aside the fact that he matriculated prior to the AAMC's 1979 Special Advisory Panel on Technical Standards for Medical School Admission,26 discussed below).
What about these technical standards? What do they say? How might they affect Moana? Most statements of technical standards use the language, logic, and structure of the just mentioned AAMC report, and therefore are organized around five domains: (1) observation skills, (2) communication skills, (3) sensory and motor function, (4) intellectual, conceptual, integrative, and quantitative abilities, and (5) behavioral and social attributes. Depending on the wording of a particular school's standard, and depending upon the type of LD being considered, LDs could fall under any or even all of these category headings. For example, under “observation skills,” one school requires that students be able to “acquire information from written documents, and to visualize information as presented in images from paper, films, slides or video.”23 Under its “intellectual-conceptual” category, this school also specifies that the “candidate must be able to measure, calculate, reason, analyze, integrate and synthesize,” and that “problem solving” must be carried out “in a timely fashion.”
Does any of this mean that a student who cannot “analyze, integrate and synthesize in a timely fashion” should be automatically rejected by the school of his or her choice? Of course not. Hopefully, that school will work with this student to design accommodations that would negate the “learning difference.” On the other hand, these standards do exist and it certainly is conceivable that a school might decide preemptively not to accept this student and further justify its decision by insisting that any such accommodations would “fundamentally alter the training program” (another legal standard pertaining to the ADA). Perhaps here is where we might find Moana turning to the court for relief.
Accommodations and the Use of an Intermediary
Thus far, our discussion of LDs and medical education has avoided referencing specific types of LD and/or related accommodations. We have taken this path because we believe that what “works” in one set of circumstances may not in another. There is, however, one type of accommodation (a personal assistant/intermediary) proscriptive, mentioned in a few of the technical standards we reviewed, that we believe warrants a few additional comments. According to one school:
Technological accommodations can be made for some handicaps in certain areas of the curriculum, but a candidate must meet the essential technical standards so that he or she will be able to perform in a reasonably independent manner. The need for personal aids, assistance, care givers, readers, and interpreters, therefore, may not be acceptable in certain phases of the curriculum, particularly during the clerkship years.23
A second says:
The use of a trained intermediary is not acceptable in many clinical situations in that it implies that a student's judgment must be mediated by someone else's power of selection and observation.27
And a third (this time a college of osteopathic medicine) notes
The use of a trained intermediary means that a candidate's judgment must be mediated by someone else's power of selection and observation.22
Although the use of intermediaries is in no way particular to LDs, the prospect that Moana may need (just as Marilyn Bartlett does) someone to read her things such as patient notes, MRI reports, PDA-based materials on drug interactions28 (assuming for the sake of discussion that Moana would even use such a device, given references in Bartlett VI that the plaintiff has difficulties with computer-base information), or even material brought in by a patient, raises a whole host of troubling questions—and images. Imagine that Moana is in clinic and has stopped for a moment to read a patient's chart before entering the examination room. What will she do (assuming for just this example that Moana does not have an LD)? One thing Moana will not do is read the patient's chart in its entirety. Nor will she read entire sections. Instead, she will skim, jumping from high point to background, to high point, etc. Although the chart may be a medically sacred text, it is neither liturgy nor canon. Instead, the reading and interpretation of charts calls for discretionary judgment. Now, let us un-suspend our disbelief and return to our “real-life” Moana. She is not able to digest this chart in 30 seconds. Nor will she be able to turn and have someone read the chart to her. After all, a chart is not something you “read.” Interpreting a chart takes considerable skills honed over time. So, to whom can Moana turn? The most obvious—but organizationally inane—answer is “another physician.” But, even here, the likelihood that two physicians would read a chart in exactly the same manner is small. Nonetheless, let us say their readings are exactly alike, and let us add that Moana's training program has assigned to her a faculty person explicitly for this purpose. What we have done is substitute one person's (the faculty person's) clinical judgment for another (Moana's). We have thus rendered Moana's clinical voice moot—and all this before anyone sets foot into the exam room, meets the patient, and adds yet a third voice to this dynamic.
At this point, we also want to point out a key modifier in the first of the above quotes: “may.” Accommodations (e.g., a personal aid) that are not appropriate in one setting (in the exam room or at the bedside) may well be appropriate in another (the classroom, an x-ray lab). This distinction underscores a point we emphasized in our earlier paper,6 namely, the difference between medical training as an end in and of itself (with the MD degree certifying satisfactory completion of training) and medical school as one step in a much longer process of “professional preparation.” Under the first set of circumstances, the focus is “degree attainment,” with issues of disability and accommodations framed from this vantage point. Doctoring and the clinical work of medicine are not at issue here. When the specter of an “unlevel playing field” is raised in an educational context,29 usually it is done so with an eye towards one's ability to compete for and attain the degree in question.
The picture changes once we take the same curricular elements but recast our focus from “degree requirements” to “outcomes” and “competencies.” Here, the focus shifts to the knowledge, skills, behaviors, and values one must possess to professionally care for—and about—patients. The degree is incidental, a veritable byproduct of the competencies acquired. Within this dichotomy (degree attainment versus competencies and professional development) lies a fundamental question and one that all medical schools must raise and explicitly answer: “What are we in the business of doing?” The answer, in turn, provides us with a framework for assessing, and establishing, accommodations. What is the field that needs leveling, attaining a degree or becoming an accomplished clinician? Are medical schools in the business of certifying the successful completion of a body of coursework (however rigorous and pedagogically exacting it might be), or are medical schools in the business of establishing the presence and/or absence in matriculants of certain core competencies necessary for the skilled and compassionate practice of medicine?
These questions take on an additional layer of complexity when we ask, “On whose behalf?” Are we “leveling fields” to better serve the student, or is society—and societal needs—our ultimate yardstick? If we answer, “student,” then our pedagogic efforts must be directed towards meeting the student's needs. If we answer “society,” then we must acknowledge a different ledger of expenditures and “reimbursements.” Society pays a hefty (if necessary) price to acquire its phalanx of highly skilled, knowledgeable, and professional physicians. One part of this cost is monetary, for medical school tuition pays for only a fraction of the cost of educating doctors.
There is, however, a second cost, one not often mentioned in the medical education literature, and one that is not well appreciated by students or their mentors—the in corpus cost of medical training. People, after all, give their bodies so that medical students might learn. In some instances, this cost may be a one-time event, as when people donate their bodies to medical schools to be used as cadavers. However, in the vast majority of instances, the transformation of patients into “learning tools” is an ongoing, ubiquitous, and often invisible part of medical training. At worse, all (student, patient, faculty, and system) hope that a medical trainee's first spinal tap (or first whatever) will result in nothing more than transient discomfort, even as the possibility of substantial iatrogenic damage looms ominously in the background. In many instances, patients are unaware of their “gift,”30 as the signing of forms and verbal approvals quickly slip into ritual. Whatever the outcome, patients give their consent, when they are allowed to, based largely on the assumption that other (future) patients will benefit, even if this assumption is more tacit than explicit at the time.
But, what if this assumption could not be taken for granted? What if some of the students who file by a patient's bedside or into the exam room went to medical school because they thought it would be “fun,” because they were “curious about medicine,” or because they always wanted to “have an MD” after their name? What if all of the embarrassing questions and physical indignities were undergone for personal, idiosyncratic, and possibly selfish reasons? Is it moral to subject patients to these “discomforts” if those who benefit most directly—the students—might not go on to take care of other sick people? Is it moral to assail patients for the singular purpose of satisfying a “course requirement?” We think not, and this is why we consider medical training a process of professional acculturation rather than a process of degree attainment composed of discrete domains of achievement. This, too, is why we consider medical education to be “undifferentiated” and therefore something that cannot be unbundled like telecommunications services or computer software.31 Here, too, is why we lack enthusiasm for arguments that begin with an “outcome” (e.g., that there are physicians with disabilities who “make contributions to medicine”) and then “reason backwards” in using this fact to support an affirmative program (admitting students with disabilities) because it may yield the desired outcomes. There are, after all, individuals who decide during their training that they would rather conduct basic science research or be an administrator than take care of patients. If they can choose such a career path, why can't someone with an LD have the same option? The difference, we believe, lies with the notion of intentionality. The medical student qua researcher is coincidental. The individual with an LD is more “preordained.” Hopefully, medical schools would not admit someone who unequivocally states during the admission process that he or she never intends to work with patients…no matter how promising that person's career as a medical researcher might be.32 To imagine otherwise presumes that there is a considerable amount of insensitivity, selfishness, and insularity within the medical education community. We might even consider such a decision to be culpable, under that oft-referenced “social contract” that occupies such a privileged position in the pages of our medical journals.
Undifferentiated Health Care Workers and Medical Hubris
While some argue (factually) that there are many physicians with disabilities, and while others point out (just as factually) that there are many places within medicine where persons with disabilities may shine and do so irrespective of their impairments, it does not follow that medical schools necessarily have an obligation to admit “otherwise qualified” applicants who happen to have a disability. Our basis for this contention lies with our observation that the call for differentiation becomes increasingly faint as we travel down the medical hierarchy. For example, nursing schools also require that applicants attest to their psychological, physical, and cognitive abilities (often under the label of “functional standards”). Although we have not gathered systematic data on this point, the nursing standards we have examined contain far more detail than the technical standards of the medical schools reviewed.
For example, one nursing program's functional standards are structured around 16 category labels, each with its own list of task-specific “abilities” (e.g., Gross Motor Skills specified five abilities including “Move within confined spaces” and “reach above shoulders—IV tubing, poles”). The other 15 categories covered the abilities of Fine Motor Skills (seven abilities), Physical Endurance (three abilities), Physical Strength (nine abilities), Mobility (six abilities), Hearing (five abilities), Visual (six abilities), Tactile (five abilities), Smell (three abilities), Reading (one ability), Arithmetic Competence (15 abilities), Emotional Stability (eight abilities), Analytical Thinking (seven abilities), Critical Thinking (four abilities), Interpersonal Skills (four abilities), and Communication Skills (eight abilities).33 Applicants who cannot affirm that they possess these “abilities” and “skills” or whose lack of them cannot be rectified by accommodations will not be allowed to apply to many nursing programs. Moreover, if a student is found to lack certain abilities during clinical training, this student will fail that part of the program, and in doing so, not qualify to stand for the nursing boards. In short, the Bachelor of Science of Nursing/ Bachelor of Arts of Nursing (BSN/BAN) degree is an undifferentiated degree, but with a specific twist not found in medicine. In many nursing programs, the qualities and qualifications deemed necessary to satisfy program requirements are the same qualities and qualifications deemed necessary to provide good clinical care. Within this framework, someone with a nursing degree is someone who can function as a nurse (as specified by the functional standards of that school).
At the Associate Degree of Nursing (ADN) level, the picture becomes more differentiated, but not in a way that would “satisfy” those who argue against an undifferentiated medical degree. ADN programs usually are offered at the community and/or technical college level. If there is an “open admission” policy in place, all students who have the “ability to benefit” (a federal standard that applies to the school as a whole) must be admitted. At this point, students who apply to the ADN program must pass minimal program requirements, the bulk of which are academic in nature (e.g., a high school diploma —or its equivalent). These standards are quite different from those required at entry for the BSN/BA level and therefore are quite different from the standards used to decide who can stand for the nursing boards. However, ADN students still must pass the same national qualifying exam as must BSN/BAN students.34 In short, at the ADN level, it is possible for a student to receive a degree but not qualify to take the national test. In the parlance of community and technical college administrators, these students have the “right to fail.”
In short, we have here two points of “difference.” First, as one peers down the “medical hierarchy,” the prospect of being defined or treated as someone who is “otherwise qualified” diminishes. Arguments that appear to “hold true” or “make sense” for physicians begin to dissipate when applied to a medical technician or an LPN with a physical, mental, or cognitive disability. There does not seem to be the same sense of “legitimacy” or “place” when we think of a lab technician who has dyslexia or a nurse's aid who cannot help transfer a patient because he has only one arm.
The second point has to do with the aforementioned likelihood of encountering a split between one's ability or right to acquire a degree from one's ability or right to be licensed as a health care provider. At the associate degree level, if someone can pass the minimal standards, then someone can seek the degree, even if it is obvious to all concerned that this individual will not be able to pass the clinical part of the program (two years in length) and/or the national test. These students do have a right to fail, something that is inconspicuously absent at the level of medical school education.
CONCLUDING COMMENTS, “COMMON SENSE,” AND THE LAKE WOBEGON COLLEGE OF MEDICINE
The Lake Wobegon Syndrome
Generally, we would have little problem accepting Little's call to “common sense” as a helpful heuristic in advancing Moana's case—
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.11
—were it not for the problematic nature of medical education as an agent of social control. The fact is, medical schools rarely conclude that someone they admit lacks the academic, technical, or professional attributes to be a physician. While numbers obviously will differ by school, medical historian Kenneth Ludmerer notes that by the 1970s, 98.5% of all matriculants were completing their four years of training. Medical school attrition, once typified by the adage, “look to your left and right—one of you will not be here by year's end,” had dropped so low as to make admission a de facto license to practice medicine.35
A “product failure rate” of 1.5% stands either as a towering testimony to the sagacious capabilities by medical school admission committees or as witness to a general inability or unwillingness by medical educators to identify those students who lack the intellectual, technical, or value qualities to be skillful and sensitive clinicians. Our own sentiments lie more with the latter conclusion than the former. It simply is inconceivable to us that admission committees are considered capable of making such exacting predictions year in and year out regarding the future capabilities of relatively young individuals to manifest excellence in a field of work that is characterized by ambiguities and uncertainties. From this reference point, we do not find Moana's record of one failed examination and three recommendations for honors36 to be indicative of either academic or clinical excellence.37 Too often, the prevailing value within the culture of medical education is “P [pass] = MD.”
Moreover, and we need to be scrupulously clear on this next point (particularly for readers who do not come from medical education backgrounds), Moana has not yet passed the graduation requirements set by her school. She has passed her “coursework,” as specified by Little, but not the “academic” demands, which would include, for most medical schools, passing Part I and Part II of the Boards. The NBME does not credential physicians, nor does it independently pass on the “fitness” of students to acquire the MD degree. Medical schools and state licensing boards set those standards, as Little notes in citing Brown University. Schools that do not like what the NBME is doing (whether it is in reference to LD policies or other issues) have every right (and statutory responsibility) to take the NBME out of the matriculation picture.38 Most schools do not.
In these and other ways, many medical schools function as a veritable “Lake Wobegon School of Medicine,” and thus a place where all of their students are “above average.”39 Within such an institutional value climate, it is not difficult to imagine how a rather strained relationship might evolve between medical schools (including the AAMC as their trade group) and the NBME. On the one side stands the NBME, vexed about its ongoing status as the “LD bad guy.”40 On the other side are medical schools, chafing at the implication that they are unduly “generous” and academically “soft” because they provide accommodations for students the NBME has deemed ineligible to receive such services. It seems to us rather unfortunate that medical students, learning disabled or not, might be held hostage by these two competing claims. (“Yes, you are a qualified LD student,” “No, you are not.”) The AAMC and the NBME need to come to some mutual understanding (perhaps a “consensus conference” is in order) about the function and meaning of medical education and the relationship of technical standards to the professional practice of medicine. If nothing else, medical educators must come to grips with the fact that the overall structure of medical education is populated by essentially autonomous fiefdoms, each holding sway over different aspects and/or stages of the training trajectory. Medical schools govern years one and two; clinical departments govern years three and four; residencies have responsibility for the years of postgraduate training; state medical boards regulate licensure; specialty organizations control specialty-based recertification; and local health care organizations oversee credentialing.41 The fact that each of these domains is responsible for one piece of a much larger and more complex formative process may be one reason why individual “units” feel compelled to “pass along” the students they “inherit” from others, even when they have some doubts about their professional competence, and even when “common sense” might dictate otherwise.42 Having said all this, we would be negligent if we did not point out once again that many medical schools operate within a Lake Wobegonish culture, where the “right to fail” has ceased to be part of the normative environment.
Possible Reasons for Admitting Students with LDs
Issues of “normative blindness” or charges of academic pandering aside, there are at least two substantive reasons why medical students with LDs should be admitted—and perhaps even sought out—by medical schools. We believe this even as we acknowledge that much of what we have said thus far suggests that we would argue otherwise. First, turning once again to the judicial system, one reason is captured by the case of Grutter v. Bollinger, where in May 2002, the 6th Circuit Court of Appeals upheld the University of Michigan Law School's decision to use race affirmatively in its admission process.43 In its ruling, the court concluded that a diverse student body is a “compelling state interest” and that diversity promotes an educational atmosphere that is “essential to the quality of higher education.” In this decision, the court cited a Supreme Court ruling, Sweatt v. Painter, that law school education “cannot be effective in isolation from the individuals and institutions with which the law interacts.”44
Why not extend these basic principles to medical education and, in turn, to students with disabilities? While it certainly is true that medical students and residents encounter a wide variety of patients and pathologies during their training, it also is true that these encounters take place within highly structured and delimited circumstances. Those who seek help are “patients.” Those who provide help are “doctors.” Disease, in turn, happens to people “out there,” or more specifically, to people who are “not me.” In these and related ways, students come to internalize more of the “detached” side of Renee Fox's famous concept of “detached-concern.”45 From this vantage point, it may be extremely important that medical educators be challenged to design learning environments, competencies, and related socialization experiences around the appreciable presence of individuals with disabilities. Perhaps one goal might be to have the number and types of disabilities reflect the morbidity and impairment patterns that exist within society at large—recognizing that this goal, as framed here, is more about “counting” than it is about specifying desired competencies and their related outcomes. In short, we are inclined to suggest to Moana that Grutter v. Bollinger could be more relevant to her situation than is Bartlett VI.
There is a second reason for affirming the presence of medical students with disabilities within the training pipeline. We believe that current thinking about medical education, including how medical education might be better structured and delivered, is nowhere close to the standards of excellence it might achieve if medical schools were “encouraged” to stretch the boundaries about what they routinely consider to be “the appropriate medical school applicant.” While it is true that medical school student bodies have become more inclusive over the past 30 years, especially with respect to gender, it also is true that medical students are more alike than different, given their high academic achievements and career aspirations.
The quality of care delivered, the types of research conducted, and even the way we think about disease have greatly benefited from the increased number of minorities and women in medicine. Moreover, those who initially pushed for more affirmative admission policies of various kinds did not necessarily anticipate the outcomes that have taken place as a result of their efforts. We confess that we have no concrete ideas about how medical education might be changed for the better by increasing the number of matriculants with disabilities. Similarly, we cannot imagine how the interjection of these “strangers” will change how medicine will think about disease, except for our blind faith that change will take place. There is an old hockey adage: “You don't improve if you only skate against yourself” (i.e., against players who are at your skill level). Think about it.
Villains and (Potential) Saints
If there is a villain in this overall story, it does not reside with an “insensitive” NBME or with those who feel that Marilyn Bartlett should not be allowed to practice law because she represents the diminishment of professional standards. The actual villain, if we may use the term, resides within the medical school itself, in the guise of an admission process that continues to be consumed with measures of academic performance and as a result with markers of “academic dis-abilities.” Legions of reports and commissions have attempted to loosen academic medicine's fearsome dependence on GPAs and MCAT scores, so readers might excuse us if we appear skeptical about the prospects of meaningful change. Nonetheless, we could begin by creatively working within some of the challenges issued by Dr. Jordan Cohen in his annual address at the 2001 AAMC annual meeting in Washington, D.C.46 In particular, we wish to consider Cohen's six ideas for reforming the admission process, along with his observations on how we emphasize those “more easily measured indices of academic achievement” and how this approach to admission sends “distorted signals” to students about what we seek in future physicians. Actually, we would quibble on only one aspect of Cohen's conclusions. It is not the signals that are being distorted.47 The various messages, latent and manifest, that are contained within the admission brochures, the supplemental forms, and the interviews do an excellent job of conveying the message schools want to send, namely that while students might desire to become skilled and compassionate physicians, they first must demonstrate their academic dedication and prowess—something that emphasizes the “medical student” role rather than the role of “future physician.” The issue before us is one of “identity,” and by stressing academic prowess, medical schools disenfranchise students with LDs, not because they are unworthy of becoming physicians (the “second-order” goal, and something medical educators admit they cannot predict), but because they are deemed “at risk” for the basic science years and thus for the role of “medical student.”48
The problem for the Moanas of this world is that these roles and identities are not inclusive when it comes to medical school aspirants with LDs. In Bartlett VI, Judge Sotomayor ruled that diagnostic tests were not sufficient to establish the presence of an LD—something that sounds startlingly similar to GPA and MCAT scores not being sufficient to establish the presence of a “good doctor.” Perhaps someday, someone can figure out how best to “sue” the institution of medical education, and in doing so legally prod medical educators into abandoning their penchant for GPA and MCAT scores as screening tools. More than likely, all of this will happen only when we stretch our pedagogic imaginations, and in doing so, focus on how medical curricula and medical training can be “handicapping” rather than how this or that medical student is “handicapped.”
1The authors consider the term “person with a disability” to be more sociologically and epistemologically correct than the oft-referenced “disabled person.”
2Kolchik S. Hearing repaired: former Miss America hopes to enter “real world.” USA Today. August 8, 2002, 9D.
3The following plot description for the movie School Daze appears on 〈http://video.barnesandnoble.com/search/product.asp?ean=43396058347〉, accessed 11/1/02: “Fraternity and sorority members clash with the other students at a historically black university in this politically charged musical, which marked the sophomore feature from director Spike Lee. Dap (Laurence Fishburne) is a politically conscious brother who leads anti-apartheid demonstrations and eschews the social climbing of the Greek system. But Half-Pint (Lee), his craven young cousin, is willing to endure any humiliation to join the manly Gamma fraternity. As Half-Pint tries unsuccessfully to impress the Gammas with his inept womanizing, Dap engages in philosophical debates with Rachel (Kyme), his girlfriend. Meanwhile, the light-skinned, straight-haired sisters of the Gamma Ray sorority battle it out in a beauty parlor with their darker-skinned, Afro-headed fellow co-eds. Eventually, Half-Pint gets the chance to join the frat, but only after a degrading episode with Jane (Tisha Campbell), the soon-to-be ex-girlfriend of his house president, causes Dap to lose all respect for him. Based in part on the director's experiences at Atlanta's Morehouse College, School Daze was also written and produced by Lee. Despite production numbers that included “Straight and Nappy,” a dis-fest between the “wannabes” and “jigaboos” on campus, the biggest hit on the film's soundtrack was the go-go anthem “Da Butt,” E.U.'s ode to shaking one's backside.”
4The fact that both Lee and Howard, in all likelihood, could make their own films about schisms within the “disability community” says something, we believe, about the relative status of disabilities versus race within the general public consciousness.
5“Normals” is a term sometimes used within the disability community to ironically capture the fundamental truth that those who do not currently have an impairment are “waiting to become disabled.”
6Claiming the “right” to speak or write about disabilities because one has a disability is a double-edged sword. What may be “gained” by claiming such a prerogative, grounded as it is in one's own status as a person with a disability, comes at the cost of denying “outsiders” the liberty to speak with any semblance of authority on this topic and therefore transforming dialogue into monologue. It is with misgivings, therefore, that we have decided to note that one of the authors (FWH) has multiple impairments (hearing, mobility, and learning), and that the other author [GGG] works with individuals who have disabilities, including LDs, as an academic counselor at a community technical college. Coincidentally, there are a number of similarities between the “disability careers” of Marilyn Bartlett and FWH, including the academic problems associated with LDs at the undergraduate college level and the necessity of acquiring accommodations for a graduate-level language requirement (his for Spanish, hers for German). In short, the authors have strong personal and work-related experiences with disabilities and education and admittedly are sympathetic to the general claim that individuals with disabilities routinely encounter marginalizing stereotypes, and that having an LD says nothing about a person's intelligence or ability to make a contribution to society.
7Hafferty FW, Gibson GG. Learning disabilities and the meaning of medical education. Acad Med. 2001;76:1027–31.
8Parsons T. The Social System. New York: Free Press, 1951.
9Leo J. Let's lower the bar. U.S. News & World Report. 1998; October 5: 19.
10Barrett D. Dyslexic beats the bar. Last Update 2001. Available from 〈http://www.dyslexia-adults.com/a43.html〉. Accessed 11/1/02.
11Little D. Learning differences, medical students and the law. Acad Med. 2003;78:187–8.
12 Bartlett v. New York State Board of Law Examiners 93 Civ. 4986 [SS] 2001
13We refer to the classic World Health Organization (1980) distinctions among impairment (a physiological, anatomical, or psychological loss or abnormality of function, e.g., deafness), handicap (a social or environmental disadvantage resulting from impairment or disability, e.g., difficulties in communication), and disability (a restriction of functional ability and activity caused by an impairment, e.g., loss of hearing). Given these definitions, an individual with an impairment need not be disabled, nor would a person with a disability necessarily have a handicap.
14Two legal principles articulated by Supreme Court Justice Oliver Wendell Holmes are pertinent to our arguments. The first appears in his famous essay “The Path of the Law,” where he asserts that it is not the law that decides the outcome of individual court cases, but rather what judges say is the law. (Novick SM, ed. The Collected Works of Justice Holmes: Complete Public Writings and Selected Judicial Opinions of Oliver Wendell Holmes, vol. 3. Chicago, IL: University of Chicago Press, 1995:393.) The second principle appears in his dissent in Lochner v. New York, 198 U.S., 45, 76 (1903): “General principles do not decide concrete cases.”
15Marilyn Bartlett took, and failed, her first bar exam in 1991. Between 1991 and 1997 (the date of her first appearance before the 2nd U.S. Court of Appeals), Bartlett took the bar exam five times. Subsequent to the Court's 1997 decision (which did require accommodations), Bartlett took her sixth exam and failed, this time because of personal circumstances that “affected her ability to take the July 1999 bar examination” (see page 4 of the above-referenced endnote 12—2001 legal ruling). There is, however, some confusion about how many times Marilyn Bartlett has taken the bar exam with accommodations. On page 15 of her 2001 ruling, Judge Sotomayor specifies that there were “three separate occasions in which she was provided with accommodations.” On page 36, however, Sotomayor notes that the plaintiff “has failed the New York Bar on two separate occasions with accommodations—once in July 1993 and once in July 1999.” In any event, the August 2001 decision once again ordered that Bartlett receive a specific list of accommodations. As of this writing (November 2002) there is no record that Marilyn Bartlett has passed the New York State bar exam.
16For the sake of brevity, we refer to Bartlett v. New York State Board of Law Examiners 93 Civ. 4986 [SS] 2001 as “Bartlett VI,” even though there is no such designation in the current legal literature.
17Professor Little uses the term “learning differences” throughout her paper. The corresponding legal and medical term is “learning disability.” (See endnote 3 for additional observations on the issue of word choice.)
18 Sutton v. United Air Lines, Inc., 527 U.S. 471 (1999), Murphy v. United Parcel Serv., Inc., 527 U.S. 516 (1999), and Albertson's, Inc. v. Kirkingburg, 527 U.S. 555 (1999).
19We do not argue that Bartlett VI is of absolutely no relevance to future judgments by the courts, but we do feel that much rests on the issues being raised and the setting being addressed by those issues. In all likelihood, the Bartlett VI decision should change little at the medical school level where most students with LDs receive accommodations. Whether this practice will influence decision making at the NBME level is more to the point, but something about which we do not wish to hazard a guess. More applicable (and insightful) is Oliver Wendell Holmes' famous dictum about the relevancy of “legal principles” to decisions rendered by judges. See endnote 14 for the pertinent quote.
20It is with no little irony that we point out in this context that Moana's status as a graduate of an MD program would not automatically qualify her for entry into a physician assistant or registered nurse program, based on the fact that the latter programs often have more stringent or detailed technical/functional standards. Moreover, the standards employed by these health occupations are more likely than those employed by MD programs to specify that an applicant be able to perform nursing or PA work and not simply be able to pass the course requirements for a degree.
21A word search for “technical standards” in the Academic Medicine online database yielded three hits. Two of the publications identified were brief synopses of medical school programs in a supplemental issue on medical education (Faulkner LR. University of South Carolina School of Medicine. Acad Med. 2000;75(9 suppl):S342-S348; Curry RH, Thomas JX Jr. Northwestern University Medical School. Acad Med. 2000;75(9 suppl):S104–S106). The third was an article on professionalism (Frankford DM, Patterson M, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75:708–17). In the former two instances, one used the term in reference to computers in medical education and the other in a passing and non-detailed reference to the existence of technical standards at the particular medical school being reviewed. In Frankford et al., the phrase was used in a general context without any reference to issues of “abilities” or “dis-abilities.”
22This quote is taken from the technical standards statement for Saint Louis University School of Medicine. See 〈http://medschool.slu.edu/bulletin/〉, under the “Admissions” button. Accessed 11/03/02.
23The quote comes from the technical standards statement of the University of Michigan School of Medicine. see: 〈http://www.med.umich.edu/medschool/students/admissiontechnical.html〉. Accessed 11/03/02.
24Yeshiva 1998. See: 〈http://www.yu.edu/news/yutoday/dec98/AECOMalum.html〉. Accessed 11/03/02.
25See the American Society of Handicapped Physicians at 〈http://www.health.gov/nhic/NHICScripts/Entry.cfm?HRCode=HR1903〉. Accessed 11/03/02, and the Canadian Association of Physicians with Disabilities at 〈http://www.capmr.medical.org/formation_capd_.htm〉 Accessed 11/03/02.
26Association of American Medical Colleges. Report of the Special Advisory Panel on Technical Standards for Medical School Admission. Washington, DC: Association of American Medical Colleges, 1979.
27From the technical standards statement of the University of Michigan School of Medicine. See: 〈http://www.med.umich.edu/medschool/students/admissiontechnical.html〉. Accessed 11/03/02.
28PDAs (personal digital assistants) are fast becoming a ubiquitous part of clinical medicine. A variety of applications target medical users. One of the more popular types of programs allows physicians to check for drug dosages and interactions when prescribing medications for their patients.
29The metaphor of an “unlevel playing field” frequently appears in discussions about and references to issues of LDs. Judge Sotomayor's decision is only one of many examples.
30Gawande A. The learning curve: like everyone else, surgeons need practice. That's where you come in. The New Yorker. 2002; January 28: 52–61.
31Analogies to other types of organizations and companies can—and probably should—be considered. Taken to its illogical conclusions, one might consider medical education as something akin to a Burger King Whopper, with its promise that you can “have it your way.” Under such a model, the medical school curriculum would be completely elective, with students signing up for courses and training experiences based solely on their self-identified needs and future job expectations. Standing for and successfully passing the boards would be the solitary requirement. Under such a system, if students passed this hurdle, even without a shred of prior coursework, they would qualify for residency training—a point at which some medical insiders consider “true” medical education to begin. Conversely, an inability to pass “boards,” no matter how much coursework was taken, would bar one from postgraduate training—essentially the system we have now.
32We do not discount the importance of the physician-researcher or of MD–PhD programs. We wish only to cast a dusting of aspersion on the specific case of those who demand an MD degree while intentionally rejecting any future responsibilities for patient care. It is our opinion that these individuals can better assuage their desire to do clinical research by securing an appropriate PhD degree.
33See “Functional Abilities of Nurses,” Lincoln University of Missouri at 〈http://www.lincolnu.edu/∼nursing/aasfunc.abilities.htm〉. Accessed 11/03/02.
34In another interesting twist, graduates of BSN/BAN programs who do not pass the nursing licensing exam may not call themselves “RNs.” Rather, they become “graduate nurses,” a time-limited job classification under which they may perform limited nursing duties until they retake, and pass, the licensing exam. In contrast, physicians who graduate from medical school may call themselves “MDs” and may do so irrespective of passing Part III of the boards. In short, you can put the designation BSN after your name but you cannot call yourself an “RN” unless you are certified to work as a nurse. You can, however, call yourself a “doctor” even though you are not licensed to practice medicine.
35Ludmerer KM. Learning to Heal: The Development of American Medical Education. New York: Basic Books, 1985.
36Moana did not receive a grade of honors. Rather she garnered three recommendations for honors. Moreover, the structure of clinical clerkships, with its multiple physician contacts, would dictate that these three recommendations came from the dozens of clinicians who evaluated her during her clerkships, and not a more limited subset.
37We must rush to add that we are not criticizing Moana's record or her capabilities–except for Little's acknowledgement that Moana cannot “read or analyze quickly.”
38The fact that state licensing boards can independently set their own standards leads to those situations where a medical school decides not to require passage of Part 1 to matriculate into year three but where the relevant licensing board (and all do) requires that applicants pass all three national board exams. Given the different foci of these three exams, it is entirely likely that a fourth-year student is more qualified to pass the Part 2 exam (with its focus on basic science and clinical knowledge) than the Part 1 exam (with its focus on basic science knowledge).
39In recounting her own arrival at Harvard Medical School, physician and author Perri Klass observes: “What they tell you, of course, is that…some of you will be superb…and the rest of you will be merely excellent.” (Klass P. A Not Entirely Benign Procedure: Four Years as a Medical Student. New York: G. P. Putnam's Sons, 1987.)
40In all fairness to the NBME, as well as to the heterogeneous nature of LDs, it is entirely plausible that an individual requesting and receiving accommodations for Part 1 of the boards would not qualify for the same accommodations (or any accommodations at all) for Part 3. In this same way, different parts of a single board exam may require different types of accommodations, including, again, the possibility of none at all.
41The Case for Medical Education Reform [theme issue]. Health Aff. 1988;7: 5–172.
42See Pulitzer Prize-winning author James Stewart's book Blind Eye for the quite horrifying details about how serial killer and physician Michael Swango made his way through the medical educational process. Stewart JB. Blind Eye: How the Medical Establishment Let a Doctor Get Away with Murder. New York: Simon & Schuster, 1999.
43 Grutter v. Bollinger, 288 F. 3d 732 (2002).
44 Sweatt v. Painter, 339 U.S. 629, 634, 70 S.Ct. 848, 94 L.Ed. 1114 (1950).
45Lief HI, Fox RC. Training for “detached concern” in medical students. In: Lief HI, Lief VF, Lief NR (eds). The Psychological Basis of Medical Practice. New York: Harper and Row, 1963.
46Cohen JJ. Our compact with tomorrow's doctors. Acad Med. 2002;77: 475–80.
47The admission process represents what some might consider the first of many hidden curriculums that medical students encounter during their training—this one taking place even before students are accepted.
48Medical educators have long acknowledged that their predictive models of “success” take us little beyond the first two years of medical education and therefore shed little light on who will turn out to be a “good physician.” Similarly, educators acknowledge that some of those who will shine in the first two years of training will not be at the head of the line when it comes to working with patients. In short, medical school applicants with LDs are “dismissed” not for their lack of potential in becoming skilled and effective physicians—something medical school cannot predict—but for their inability to shine during the clinical years, something that will have an impact–not so incidentally—on a school's ranking in the U.S. News and World Report's rating of medical schools. (For a description of the ranking system and the variables used, see 〈http://www.usnews.com/usnews/edu/grad/rankings/med/medindex.htm〉. Accessed 10/3/02).