The World Health Organization’s International Classification of Functioning, Disability and Health (ICF),1 as endorsed by the Institute of Medicine (IOM),2 expands the American Medical Association definition of disability based on physical limitations3 to include social, environmental, and policy barriers preventing individuals with disabilities from participating fully in daily and community life.1 While 20% of America’s population has a disability,4 less than 1% of medical students do,5–7 a percentage well under the 3.2% rate of disabilities in their 18–24 age group.8 Severe underrepresentation of people with disabilities is problematic because health care professional diversity improves patient outcomes.9–11
The Americans with Disabilities Act (ADA), enacted in 1990 and strengthened by amendment in 2008, functions with the Rehabilitation Act of 1973 (RA) to prohibit discrimination against people with disabilities.12 Section 504 of the RA applies to “any program or activity receiving federal funds,” including educational institutions such as medical schools, and proscribes discriminating against an “otherwise qualified person with a disability.”13 The ADA covers places of “public accommodation” including private hospitals, universities, and medical schools.14 Like Section 504, it prohibits higher education institutions from denying admission to or discriminating against qualified persons because of a disability,15 and requires the provision of reasonable accommodations to provide an otherwise qualified applicant an equal opportunity to participate in the institution’s programs.16
Jordan J. Cohen, when president of the Association of American Medical Colleges (AAMC), established the principle that physicians should look like their patients. His 1997 proclamation included gender, racial, and ethnic parameters and was updated in 2004 to include disability.17,18 Studies have shown that patients prefer physicians who are race/ethnicity concordant,19 outcomes may be better when physicians look like their patients,20,21 and physicians with disabilities appear more empathetic to patients with and without disabilities than physicians without disabilities.22–25 The Liaison Committee on Medical Education (LCME) supports students with disabilities. Their 2014 standard states, “A medical school develops and publishes technical standards for the admission, retention, and graduation of applicants or medical students with disabilities, in accordance with legal requirements.”26
Medical schools use technical standards (TSs) to assess applicant eligibility for admission and stipulate the extent to which accommodations are made for students with disabilities during medical school. The AAMC provides no standard wording; each school decides this independently. Feasible technological solutions exist to accommodate students, and TSs requiring full sensory and motor abilities for admission impose nearly impenetrable barriers for applicants with disabilities. The courts have clarified that “in determining whether an individual meets the ‘otherwise qualified’ requirement of [the disability statutes], it is necessary to look at more than the individual’s ability to meet a program’s present requirements.”27 A school must make reasonable accommodations. Legal protection remains elusive, however, because schools and courts determine whether something is a “reasonable accommodation”—an accommodation interpreted by a school as fundamentally changing the usual approach to education could be judged as unreasonable.27,28 There is no consensus among state licensing authorities regarding essential physical and cognitive capabilities for medical education, and scant evidence exists about how specific accommodations impact patient or professional outcomes.29
TSs and acceptance of students with disabilities vary. Eickmeyer and colleagues surveyed United States medical schools (53% response rate) and found that many make individual decisions regarding TS legal language rather than using ADA guidelines.7 Some accommodate such students while others do not.25,28 TSs of the latter are often based on the philosophy that all medical school graduates should receive an undifferentiated education, a debatable proposition considering that 69.8% of almost 3,000 medical students and physicians disagreed with this requirement.24
In 2008, Congress passed the ADA amendment to clarify its intent that protection provided by the ADA is broad, rejecting court decisions narrowing application of the law.30 Increasingly, educators support disabilities accommodations, believe restrictive TSs fail to recognize technological advances and changes in society and medicine,30 and emphasize the need to reach a national consensus on appropriate TSs for physicians with disabilities.5,31 Meanwhile, applicants with disabilities face barriers to admission from ADA nonadherence.32 Once accepted, there are additional barriers. For instance, U.S. medical students/residents with hearing loss spend up to 10 hours/week arranging accommodations, a violation of the ADA spirit if not the law itself.25
As no previous research has examined the wording of U.S. medical school TSs, our goal was to assess the availability of written TSs from every accredited school (MD- and DO-granting) to applicants applying to medical school, evaluate these relative to ADA intent, and assess factors associated with ADA compliance.
Method
Design
We conducted document analysis of written TSs of all medical schools made available to students applying for admission, focusing on physical disabilities of hearing loss, visual loss, and mobility. Psychiatric disabilities (including learning disabilities) were excluded because they are handled in fundamentally different ways than physical disabilities, may fluctuate significantly, and are often treatable, and because little information existed in the medical school TSs.
Setting
We attempted TS analysis for all 173 MD- and DO-granting U.S. medical schools.
Data collection and database construction
To simulate information available to prospective student applicants, we considered only written information provided by medical schools. Two of us (A.H., B.C.) conducted an intensive search from May 2012 to July 2014 to obtain TSs from every American school accredited by the AAMC and the American Association of Colleges of Osteopathic Medicine (AACOM). If TSs were unavailable on their Web site, we contacted the school by e-mail. If no response was received, we sent a letter through the U.S. Postal Service. Both the e-mail and letter were sent to the contact address provided on the school’s admissions Web site and written as if from an applicant.
We classified TS availability to applicants as:
- available online, and further classified by the relative difficulty finding it:
- easy (found within 5 minutes),
- moderately difficult (took 5–20 minutes), and
- very difficult (took greater than 20 minutes);
- mentioned online as “upon request” and responded to queries;
- mentioned online as “upon request” but no response;
- no mention online but responded to requests; or
- no mention online with no response to requests.
We recorded data available to students on Web sites about the school’s type (allopathic or osteopathic), private or public status, age of the school, gender distribution of the student body, racial distribution of students (% white), geographic location of the school, and class size. TSs from all sources were entered verbatim into a database.
Data abstraction procedures
The research team developed a coding scheme for TS content analysis. (Supplemental Digital Appendix 1, https://links.lww.com/ACADMED/A327). This scheme focused on three domains, with strict criteria and examples for each category. To ensure that all codes were congruent with current ADA legal interpretations, an ADA legal expert (A.O.) reviewed and made appropriate clarifications.
Domain one examined the willingness to comply with the ADA—that is, provide accommodations. Schools identified as willing specifically stated intentions to accommodate applicants with disabilities of vision, hearing, and mobility; if no statement was found in the TSs, the school was not deemed willing. (Supplemental Digital Appendix 1, https://links.lww.com/ACADMED/A327). An example of an unsupportive school is, “These … (physical) … abilities are the minimum attributes required of applicants for admission … and … who are candidates for graduation.” Domain two examined functional requirements for each of the three disabilities. Domain three examined locus of responsibility for providing accommodations—that is, whether the school, individual, or both were responsible—and the school’s willingness to provide two specific types of accommodations: intermediaries (e.g., interpreter) and auxiliary aids (e.g., scooters). An example of unwillingness to provide accommodations is, “Except in rare circumstances, the use by the candidate of … an intermediary … would constitute an unacceptable modification.”
Data coding
Coding and coding scheme refinement occurred iteratively. First, two authors (B.C., C.M.) independently applied the scheme to two schools. Coding discrepancies were identified, and disagreements were adjudicated by two others (P.Z., M.F.), with the coding scheme clarified. The process was repeated twice, each time with two additional schools, after which the coding was consistent and the scheme deemed final. The two coders then independently coded and compared results for all remaining schools. Adjudication was needed only 13 times—each coder’s choice was selected approximately half the time.
Data analysis
We calculated descriptive statistics for school-level variables: status (private or public), age, race and gender composition, geographical region, and type (MD- and DO-granting). T tests and chi-square tests of comparison were done to identify differences between private versus public and MD-granting versus DO-granting schools. We compared TS availability and willingness to accommodate between groups using chi-square or Fisher exact test as appropriate. We conducted chi-square analyses for associations between willingness to accommodate, locus of responsibility, requirement of functional level, and willingness to provide accommodations. Statistical analysis was carried out in IBM SPSS statistical software version 22 (IBM SPSS Inc., Armonk, New York).
The University of Michigan institutional review board exempted this study.
Results
Demographic data on the 173 schools studied differed among school types (Table 1). MD-granting schools were generally older (P < .001) with smaller class sizes (P < .001). MD-granting (P = .004) and public schools (P = .05) generally had higher percentages of nonwhite students.
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Table 1: Characteristics of 173 U.S. MD-Granting and DO-Granting Medical Schools, From a Study of Compliance With the Americans with Disabilities Act, 2012–2014
Overall, 84% of medical schools (118 [86%] MD-granting and 28 [80%] DO-granting schools) had TSs available on their Web sites (Table 2). Of the 27 (16%) schools without online TSs, 12 (7%) stated that they were available upon request, and all but 1 complied when contacted; for the 15 (9%) schools with no online mention of TS, 11 did not respond to two inquiries. Thus, 10 (9%) MD-granting and 2 (6%) DO-granting schools did not provide TSs in response to the “student inquiry.” TSs obtained from the remaining 161 (93.1%) schools were used for this analysis. No statistically significant difference existed between school type or status in student ease of obtaining TSs.
Table 2: MD- and DO-Granting U.S. Medical School Technical Standards and Willingness to Accommodate Hearing, Vision, and Mobility Disabilities, From a Study of Compliance With the Americans with Disabilities Act, 2012–2014
We found that only 53 (33%) medical schools—40 (31%) MD-granting and 13 (39%) DO-granting—specifically expressed a willingness to provide accommodations; 79 (49%)—60 (47%) MD-granting and 19 (57.6%) DO-granting—had equivocal wording; and 6 (5%) MD-granting (no DO-granting) schools had language unsupportive of providing accommodations (Table 2). No information was available for 23 (14%) schools. No differences existed between school status or type.
Overall, full function of hearing, vision, and mobility was required by 30 (23%), 36 (28%), and 36 (28%) schools, respectively, for MD-granting schools, but only 3 (9%), 6 (18%), and 3 (9%), respectively, for DO-granting schools, to matriculate in medical school (Table 3). No significant difference existed between school types for hearing and vision; but for mobility, DO-granting schools were more likely to allow reasonable accommodation (P = .038). No statistically significant differences existed between school status.
Table 3: MD- and DO-Granting U.S. Medical School Requirements for Functional Level of Hearing, Vision, and Mobility, From a Study of Compliance With the Americans with Disabilities Act, 2012–2014
MD-granting schools provided less information about locus of responsibility for accommodations; only 40 (31%) schools provided this information compared with 23 (70%) DO-granting schools (P < .001). Of those with information, 9 (7%) MD-granting schools but only 1 (3%) DO-granting school had the student bear at least some responsibility, a stipulation that violates the ADA. MD-granting schools were more likely to not discuss locus of responsibility, and DO-granting schools were more likely to identify schools as having that responsibility. If only schools for which information was available were analyzed, however, no significant difference existed because of the large number of MD-granting schools without information. No statistically significant differences existed between school status.
Although few schools (3%) proscribed hearing, vision, and mobility auxiliary aids, most (58%–61%) provided no information, and the rest allowed them (Table 4). For intermediaries, 52% to 54% of schools provided information, most of whom (84%–86%) proscribed intermediaries for hearing, vision, and mobility disabilities. No statistically significant differences existed between school type or status in willingness to allow intermediaries or auxiliary aids.
Table 4: Willingness of 161 U.S. Medical Schools to Allow Accommodations for Hearing, Vision, and Mobility Disabilities, From a Study of Compliance With the Americans with Disabilities Act, 2012–2014
Schools willing to accommodate students were more likely to allow reasonable accommodations (P < .001 for all disabilities); assume locus of responsibility (P < .001 for all disabilities, though some categories had low numbers, making our findings less robust); accept auxiliary aids (P < .002 for all); and accept intermediaries (P < .001 for all). When we dropped schools without information on willingness to accommodate, the results remained unchanged, except that the association with willingness to accept auxiliary aids became nonsignificant.
Discussion
Our findings illustrate a concerning state of affairs as we celebrate the ADA’s 25th anniversary. Many U.S. medical schools appear to violate the ADA, LCME, RA, and IOM’s promotion of physician diversity.33 Nearly 20% of schools have no Web site TS access, and 7% failed to provide this information despite two direct inquiries. Over one-third of “available” standards were hard to find despite our experience searching for these. All this is remarkable considering today’s widespread Internet use.
Most U.S. medical schools’ TSs do not explicitly support accommodating students with disabilities as intended by the ADA, despite technological advances that allow accommodation of many physical disabilities without risking anyone’s health or safety.34–36 Another key finding is the prevalent proscription against intermediaries who allow some individuals with disabilities to succeed. Taken together, these findings suggest systematic exclusion by U.S. medical schools of individuals with disabilities. This is not inadvertent for some schools, based on court cases where the schools are challenging application of the ADA reasonable accommodation requirement to its applicants.28,37,38
Although few differences existed between public versus private or MD- versus DO-granting schools, we did notice that DO-granting schools seem more receptive to accommodating mobility disabilities and assuming locus of responsibility. Reasons for these findings are unclear. They could be due to many DO-granting schools being more recently established and thus having written their TSs to be compliant with the RA (programs receiving federal funds provide reasonable accommodations to people with disabilities)39 and ADA (public institutions must provide accommodations to students with disabilities). DO-granting schools’ focus on musculoskeletal medicine may explain their greater willingness to accommodate mobility disabilities.
The courts initially deferred to medical schools, allowing them to use TSs to deny participation of students with disabilities. However, as Table 5 demonstrates, recent court cases are moving to force health professions schools to allow individualized accommodations that ensure that disabled students have the same opportunity to complete the educational program as nondisabled peers.28,40,41 Still, many schools continue to apply restrictive TSs, forcing students to sue in court to enforce their civil rights.28,37,38
Table 5: Precedent-Setting Court Cases Regarding Health Profession Schools’ Technical Standards and Compliance With the Americans with Disabilities Act
Considering the IOM’s emphasis on a broader social perspective of disability, such exclusionary policies contribute to the disability of students (who otherwise could become qualified practicing physicians) by presenting additional barriers,1 as further illustrated elsewhere for physicians with hearing loss.25 Ouellette29 has reviewed legally dubious policies preventing students with disabilities from admission, and recommends that medical schools voluntarily address these versus continuing to be forced to do so by litigation.
Refusal to comply with the ADA on financial grounds seems to be on loose footing as well. While some accommodations are costly (interpreters may cost $100,000/year), others are inexpensive (amplified stethoscopes cost < $5,000). The cost–benefit ratio of such interventions is a value judgment. We believe the benefits to society of physicians with disabilities are clear. First, patients with disabilities feel more comfortable with and understood by a physician with a concordant disability42 (note that these physicians also provide care for other types of patients). Second, our personal experience as well as that of other faculty suggests that medical colleagues of students with disabilities better understand the personal reality of disabilities, and become better able to care for patients with disabilities. Third, physicians with disabilities will, when they practice, educate their communities about the life of people with disabilities. Fourth, having physicians with disabilities sends a message to society that disabilities can be overcome, even at the highest professional echelons. We believe the investment in justice and fairness provides social benefits that are well worth the financial costs.
While still few, an increasing number of physicians with disabilities are serving in clinical, educational, and research roles. Other than Moreland and colleagues’25 study, we found no studies detailing barriers for physicians with physical disabilities. We suspect that most of these professionals do experience significant barriers. One of us (C.M.) is deaf and uses sign language interpreters with patients on busy inpatient general medicine teaching services and is associate residency program director. Another (P.Z.) is deaf and chairs a leading family medicine program. The University of Michigan neurosurgery chair uses a motorized scooter. None of these three leaders would matriculate to medical school based on the TSs of many U.S. medical schools today.
Medical schools, the AAMC, and the AACOM should modernize and standardize TSs. A powerful way to achieve this would be for LCME accreditation evaluations to both require evidence of TS compliance with the ADA and ask for documentation of provision of accommodations. In addition, given the lack of consensus about what constitutes “reasonable accommodation,” the AAMC and AACOM (or IOM) should convene a task force to draft TS guidelines for medical schools to use as a template. Moreover, case studies of successful accommodations should be made available.
Our study has some limitations. Some schools may have changed their TSs during the time-intensive two-year period of data collection, abstraction, and coding, though such changes would unlikely affect the overall findings. Second, subjective elements exist when interpreting TSs. We exercised great care to develop objective, interpretable criteria to ensure accurate coding. Third, collecting data about actual experiences of students was beyond the scope of the study. It is quite possible that medical schools provide and pay for accommodations even though their TSs suggest otherwise. Fourth, there are gradations of disability, such as varying degrees of visual loss, as well as other disabilities that we didn’t investigate (e.g., communications disabilities such as stuttering) that could influence admissions decisions. We examined TSs with respect to only three disabilities. It is possible that schools are more receptive to some disabilities and gradations than was apparent on their Web site.
In sum, almost one in five U.S. medical schools do not make their TSs available online, and two-thirds of them are not willing to provide reasonable accommodations for vision, hearing, and mobility disabilities in accordance with the ADA. These findings sound a clarion call to medical education leaders to rectify the situation, and particularly for noncompliant schools to revise their TSs. Further research is needed about actual experiences of applicants with disabilities who are denied admission, students who matriculate and request accommodations, reasons for medical school reluctance to accommodate, and best practices for achieving ADA compliance. These measures will promote equitable access to the medical profession for people with disabilities, and provide the 20% of Americans with a disability the opportunity to connect with physicians like themselves.
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