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“Being on Both Sides”: Canadian Medical Students’ Experiences With Disability, the Hidden Curriculum, and Professional Identity Construction

Stergiopoulos, Erene MA; Fernando, Oshan PhD; Martimianakis, Maria Athina MA, MEd, PhD

Author Information

E. Stergiopoulos is a medical student, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

O. Fernando is a cultural anthropologist and clinical research project coordinator, Hospital for Sick Children, Toronto, Ontario, Canada.

M.A. Martimianakis is associate professor and director of medical education scholarship, Department of Pediatrics, and scientist and strategic lead international, Wilson Centre, University of Toronto, Toronto, Ontario, Canada.

Funding/Support: 2016 Ontario Medical Student Association / Associated Medical Services (OMSA/AMS) Medical Student Education Research Grant in Compassionate Care (Provider Wellness), 2016 Medical Alumni Association / Comprehensive Research Experience for Medical Student (MAA CREMS) Research Award in the Humanities and Social Sciences.

Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on social justice, health disparities, and meeting the needs of our most vulnerable and underserved populations.

Other disclosures: None reported.

Ethical approval: The University of Toronto Social Sciences, Humanities, and Education Research Ethics Board granted the authors ethical approval for studies involving human subjects as of May 2, 2016 (protocol no. 32913).

Previous presentations: Previous presentations of this work appeared at the Medical Education Scholarship Rounds in November 2016 at SickKids Hospital, Toronto, Ontario, Canada; and the Canadian Conference on Medical Education in April 2017 in Winnipeg, Manitoba, Canada.

Supplemental digital content for this article is available at https://links.lww.com/ACADMED/A560.

Correspondence should be addressed to Erene Stergiopoulos, 200 Elizabeth St., 1ES-565, Toronto, ON M5G2C4 Canada; e-mail: [email protected].

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s website (http://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=61), follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the November 2017 issue for submission instructions and for more information about this feature).

doi: 10.1097/ACM.0000000000002300

Abstract

Medical students with disabilities constitute a significant proportion of the medical student population (with estimates ranging from 3% to 13%), but they are historically underreported, undersupported, and underresearched.1–3 Indeed, the Association of American Medical Colleges has released a report to prioritize policy and services for medical students with disabilities, who face consequences for their training and future careers.4 We define disabilities, following the World Health Organization’s definition, as conditions that restrict participation or performance.5 These conditions may affect physical or mental functioning, and can include learning disabilities, sensory and mobility disabilities, mental health conditions, and physical illnesses. As a result, disabilities are incredibly varied in their chronology, causes, and implications, and they affect students’ participation and performance in diverse ways.6 An estimated 13% of medical students self-report a disability, according to a University of Aberdeen survey, reporting physical, mental, sensory, mobility-related, and learning disabilities.3 However, only one-third of students with disabilities disclosed their condition on admission or sought institutional support. Indeed, a comprehensive survey of American MD-granting medical schools reported that on average, 2.7% of students register with their accessibility office.2 Of these, the most common disabilities students disclosed were ADHD, learning disabilities, and mental health conditions.

Over the last two decades, conferences and working groups have explored the barriers that limit physicians and trainees with disabilities from disclosing their conditions and seeking support.1,3,7–9 Moreover, research on disabled health and human services practitioners and trainees has explored the mechanisms by which they become marginalized.10,11 Taken together, these studies identify barriers at relational, cultural, and structural levels, including colleague and employer attitudes and stigma, a medical culture of stoicism, and inflexibility of the medical education and health care system.7,10,12–14 At the relational level, physicians and trainees experience stigma when they are explicitly or implicitly discouraged from asking for help or from disclosing disability,3,8,12,15 or when they feel pressured by colleagues or employers to not miss shifts or classes.12,13 At the level of culture, trainees and early-career physicians face the assumption that as young people, they are unlikely to have medical problems.3 Moreover, they come up against the socialized belief among doctors that physicians are invulnerable to illness,12,14 or that “illness doesn’t belong to us.”13 Meeks and colleagues1 suggest that medical culture’s expectation of perfection for its providers frames those with disabilities as “inherently less capable of practicing medicine.” Others have argued that medical culture equates illness with weakness, and with an individual’s failure to cope appropriately.12–14,16 In turn, the profession encourages its practitioners to deny vulnerability,8,17 and provides explicit rewards for self-sacrifice.18 At a structural level, practitioners must navigate their institutions by engaging in strategic disclosure of disabilities to explain poor performance.15

These well-documented barriers are related to hidden curriculum effects within medical school. The hidden curriculum is a theoretical concept describing the learning that takes place outside of course syllabi and lecture slides, and instead emerges implicitly from institutional policies, practices, resource allocation, evaluation, and institutional nomenclature.19,20 As Hafferty notes, the hidden curriculum highlights the “commonly held ‘understandings,’ customs, rituals, and taken for granted aspects” of medical education.19 Hidden curriculum effects can either support or contradict formal learning expectations; for example, while medical school curricula may explicitly expect medical students to demonstrate compassionate attitudes, everyday practices in their school or hospital may teach them otherwise. In the case of medical students with disabilities, one study found that these students reported multiple challenges, including attendance difficulties due to ill health or clinic appointments; funding issues due to transport or special diets; and challenges with ward and surgery assignments due to pain, visual, or hearing disabilities.3 Another study found that students with personal illness experiences achieved lower test results, and higher levels of anxiety associated with failing to perform to expectations. However, in contrast to these effects, subsequent interviews with their clinical teachers also revealed that they were perceived as more mature, more compassionate, and better learners, leaving the reader to wonder why this aspect of their learning did not translate into good test scores.9

Students with disabilities hold dual roles as both service users and service providers, and have access to various socializing experiences because of those roles. These dual roles provide a largely unstudied perspective for understanding the hidden curriculum in medical training, and the impact of stigma on students’ ability to construct their identities as both health care providers and patients.3 To our knowledge, previous literature examining professional identity construction among medical students has not addressed the experiences of students with disabilities. As a result, our study aims to understand how students relate to their identities as patients in medical training, and how their experiences as health care users affect both their approach to training (including disclosure and support seeking) and their attitudes toward peers, instructors, health care providers, and patients. In doing so, we hoped to uncover institutional strategies to address stigma, and to support the wellness of students who face it. Moreover, this study set out to identify structural and sociocultural components of training, including hidden curriculum effects, that may hinder or help students’ capacity to succeed as learners and practice as compassionate doctors.

Method

We used a combination of semistructured interviews and thematic analysis of a text archive related to medical student wellness in Canada. We applied principles of critical discourse analysis to analyze routine practices and socializing experiences that expanded or limited the learning opportunities of students with disabilities. We analyzed students’ professional identity construction at relational, cultural, and structural levels to answer the question of how medical students with disabilities experience and navigate their dual roles as students and patients.19–23 Moreover, using the analytic lens of the hidden curriculum, we sought to answer how institutional policies and practices shape those experiences.

Participants and setting

We recruited a purposive sample of medical students from all years of study at the University of Toronto Faculty of Medicine. Typically, saturation around core concepts occurs between 6 and 8 participants, when the participant group is fairly homogeneous.24 We aimed for 10 to 12 to allow room to focus iteratively on core conceptual attributes; saturation therefore occurred around discourses and practices that emerged as important in our analysis and that repeated themselves across participants’ experiences.25 Following ethical approval by the University of Toronto Social Sciences, Humanities, and Education Research Ethics Board, a call for participation via e-mail listserv invited current medical students with a self-identified disability to participate in a 45- to 60-minute interview about their medical school experiences. Three calls were distributed between July and September 2016. To address possible sampling bias related to students’ possible fear of disclosure, the call detailed that the interviewer was unaffiliated with the medical school; that interviews would be kept secure, confidential, and deidentified prior to analysis; and that participation in the study bore no impact on academic standing. Fifteen students responded to the call, and 10 students proceeded to participate. We conducted semistructured interviews covering students’ relationships with peers and faculty; attitudes toward the curriculum; impact of their condition on their training; disclosure; and use of supports (see Supplemental Digital Appendix 1, available at https://links.lww.com/ACADMED/A560). The questions were developed following our comprehensive scoping review of literature on physicians and medical trainees with disabilities.3,12,13,15,16

Data collection and analysis

Phase one of the study involved in-person semistructured audio-recorded interviews to provide direct access to the social experiences of participants, including their attitudes, perceptions, and sense of identity. Interviews provide richer data than surveys in the form of both details and description, and thus allowed us to develop a more nuanced understanding of how participants perceived the effects of their disability on learning.26 Given the stigma associated with disability, interviews also allowed us to probe with sensitivity around topics that participants might otherwise be reluctant to discuss in focus groups.27 In a pilot phase, we participated in trial interviews, which allowed for refining interview questions and approaching the data collection process with reflexivity. Given that participants disclosed personal information, the pilot phase ensured that the interviewer was appropriately sensitive toward participants’ narratives, without deviating from project goals. Following this, one member of our research team (O.F.) conducted interviews between July and December 2016. Interviews were transcribed by a professional transcription service and deidentified, and then inputted into NVIVO software, version 11 (QSR International Pty Ltd., Victoria, Australia) for qualitative analysis (by E.S.).

The analysis drew from principles of critical discourse analysis, a tool used in cultural studies, sociology, and philosophy to uncover the ways in which language and social practices negotiate, legitimize, and reproduce the way we understand specific phenomena.28,29 In particular, we applied the concept of “discourses” from critical discourse analysis, which describe “practices that systematically form the objects of which they speak”20—in other words, how specific topics are discussed in medical education spaces. In doing so, we identified how learners understood the identity positions available to them, as well as aspects of the hidden curriculum that influenced those understandings. This methodology analytically helped us be attentive to how language and social practices shape the way learners understand their training into the physician role.28,29 To do so, we used codes and themes to analyze the interview transcripts, capturing the relational, cultural, and structural aspects of learners’ experiences. We developed initial codes based on a scoping literature review on medical trainees with disabilities, and refined these codes while introducing new codes as these became salient through ongoing repeated reading and reflection via memos. Themes emerged through the process of reading and journaling, and we confirmed saturation of major themes via iterative reading of the transcripts and multiple team meetings. To refine the codes and analytical conclusions, we drew from sociocultural theories of professional identity construction and Erving Goffman’s dramaturgical analysis.22,23,30 Our reading of participant experiences highlighted tensions they experienced navigating misaligned discourses of performing as a “good student” and “good patient.” We thus used social identity complexity theory, which provides a conceptual framework for how individuals perceive and structure their multiple group identities.31 Moreover, following the work of medical education scholars such as Bleakley and Hodges, we drew from Goffman’s model of dramaturgy in social interactions to understand how participants managed their performance of multiple social roles.32,33 In particular, we applied Goffman’s concepts of “front stage” and “back stage” to analyze how students perceived the expectations for their given roles when they were observed (front stage) versus how their self-perceived performance differed when not observed (back stage).30

The second phase of research took place from January to March 2017 and involved producing and analyzing an archive of publicly available texts related to medical student health in Canada. By linking data from interviews with this text archive, we sought to contextualize trainees’ experiences at one medical school within a broader national context. In doing so, we expanded the scope of this study to consider the educational policies, experiences, and practices that shape the learning environment experienced by medical learners with disabilities across Canada (see Figure 1, Table 1). Texts included medical student blogs, student handbooks, official medical school policies, and student affairs websites from all 13 Canadian English-speaking medical schools. In total, we retrieved 323 texts (180 institutional texts, 143 student blogs). We identified texts on the basis of their relation to student support services, wellness, accommodations, and articulated expectations for student behavior and performance. To do so, we searched and selected individual medical schools’ student affairs webpages, policy webpages related to absences and accommodations, and existing university-affiliated medical student blogs in Canada. One researcher (E.S.) conducted the analysis, informed by themes that emerged from the interview transcripts. This second phase of research examined in particular the structural effects of the hidden curriculum by providing the broader institutional context of our study participants. The analysis of both phases was reviewed and refined in several team meetings.

T1
Table 1:
Data Sources and Analytic Conceptual Framework, From a Multiuniversity Study of Canadian Medical Students’ Experiences With Disability and Professional Identity Construction, 2016–2017
F1
Figure 1:
Diagram of data sources and conceptual framework of analysis, from a multiuniversity study of Canadian medical students’ experiences with disability and professional identity construction, 2016–2017.Abbreviation: SICT indicates social identity complexity theory.

Results

Ten medical students participated in the first phase of the study (see Table 2). The study’s conceptual framework was structured around the relational, cultural, and structural components of participants’ experiences: It captured their perceptions of navigating dual patient–student roles, and how specific institutional policies, practices, and language shaped those experiences (see Table 1). Analytically, coding identified participants’ educational and social experiences related to their learner and patient identities, including catalytic instances of socialization that informed participants’ approaches to their patients, peers, and supervisors.34 The analysis of student blogs in the text archive followed the same approach, while coding of institutional texts in the archive focused on specific institutional language, practices, and policies around wellness, accommodations, and disabilities (see Table 3 for coding framework).

T2
Table 2:
Demographic Characteristics of 10 Medical Students by Year of Training, Self-Reported Condition, and Time of Diagnosis, From a Multiuniversity Study of Canadian Medical Students’ Experiences With Disability and Professional Identity Construction, 2016–2017
T3
Table 3:
Data Coding Structure Used for Analysis of Interviews and Text Archive, From a Multiuniversity Study of Canadian Medical Students’ Experiences With Disability and Professional Identity Construction, 2016–2017

The discourse of medical school: The “good student” and the “good patient”

Our analysis of medical school discourses revealed two distinct roles: the “good student” and the “good patient.” These discourses (as they were perceived by participants, as well as reflected in institutional materials) operated as cultural scripts and affected how students experienced their learning and negotiated their identities as practitioners and patients (see Table 3). As such, the results revealed ways in which the hidden curriculum—mobilized through specific resources, language, and policies—shaped learners’ experiences.

The perceived “good student” was one who juggled rigorous academic demands with active social commitments while maintaining excellent evaluations. This student could regularly forego sleep and exercise in the face of higher-priority demands like studying or social activities. Several participants described their inability to meet these expectations, and expressed concerns about peers’ reactions to their limitations (see Table 3). At a relational level, this revealed a concern that any inability to perform the expected student role might be perceived as laziness or incompetence. As one preclerk, with self-identified physical and psychological issues, noted:

I didn’t mind having people know [about my condition], because I was functioning at such a low level. I didn’t want people to think that that was how I normally functioned. I wanted people to know that there was a reason why I … couldn’t do what I was supposed to be doing, as opposed to running the risk of people thinking that I’m lazy or something like that.

Similarly, at cultural and institutional levels, the “good student” discourse reflected an emphasis on academic excellence. While student affairs offices encouraged students to practice self-care for their wellness, wellness itself was often explicitly framed as a tool for optimizing “peak performance” or even construed as a competition. Wellness, therefore, was mobilized as a means to perform the ideal student role. Official medical student association blogs reflected this positioning, for example, when they encouraged students to engage in extracurricular activities to increase their “efficiency” when returning to their school work (see List 1). However, wellness was not always framed as a means to attaining optimal performance; several sources explicitly stated that wellness was a means to maintaining “balance.”35–37

In contrast, the perceived “good patient” managed their condition by limiting their activities to prioritize health and self-care. In interviews and student blogs, this theme emerged from students’ observations about their own patient experiences, plus their experiences as trainees in which they observed how health care systems rewarded or penalized specific patient behaviors. For example, several participants described how clinical preceptors’ behaviors changed toward so-called “difficult” patients who did not comply with treatment expectations; these behaviors included avoiding these patients on rounds, and expressing negative attitudes about them within the health care team. Participants expressed their discomfort in these situations and felt that they had witnessed unjust patient treatment. Moreover, one clerk strongly identified with a “difficult patient” who had been discussed uncharitably by the team, and related to having one’s priorities at odds with one’s care providers. In contrast, the “good patient” was a low-maintenance health care user, who regulated negative feelings and remained positive (see Table 3). These demands conflicted with the demands of the “good student” role and often resulted in students having to shift their priorities to accommodate their health. In some cases, students accessed accommodations from their university, in the form of deferred exams, extra time on evaluations, leaves of absence, and altered clerkship schedules. However, 2 of 10 participants did not reach out for institutional support out of lack of perceived need, despite experiencing potential challenges with scheduling and clinical placements. In more informal contexts, students navigated their patient role via graded levels of disclosure to peers and supervisors, typically to excuse declining performance or to explain strong emotional reactions to in-class or clinical scenarios. For instance, students might not disclose their specific disability to a faculty member (because of concerns over privacy or evaluations) but felt comfortable mentioning that they were managing a health issue more generally. Moreover, some participants created informal networks of support by disclosing their condition to peers or supervisors.

While disclosure in individual settings occurred in many forms, the institutional language around accommodations—and the necessary disclosures required to access them—also varied significantly. In some cases, medical schools outlined specific and detailed procedures for students to access appropriate accommodations38; however, in others, there was cursory to no mention of accessibility services and available accommodations.39 Explicit guidelines around conditions meriting accommodations also varied: In most cases, universities that explained the accommodations process framed disabilities as conditions that students self-identified, and verified through medical documentation.38,40 However, in one case, a university outlined more stringent guidelines for conditions meriting accommodations, including a requirement that the condition’s consequences be “unforeseen” and “very serious, even potentially devastating”—and, moreover, that the accommodations request “shouldn’t cause the medical school undue hardship or difficulty.”41 These institutional messages frame the ways in which members of the medical school community understand the role of student services; in so doing, they implicitly comment on the appropriateness of including students with disabilities in medical training in the first place.

The patient–trainee identity

Our participants described diverse and nuanced patient–trainee identities. They self-identified with a range of disabilities that had placed them in a patient role, with varied timelines of diagnosis. These timelines were significant for assessing perceived group membership. For example, the four students diagnosed before medical school tended to use “I” and “they” pronouns to separate themselves from their health care teams when discussing their patient experiences. In contrast, the six participants who became patients during their training used “we” pronouns when describing their health care team’s decisions, demonstrating a sense of shared understanding and power as members of the same group. As one participant diagnosed during medical training described of their physician, “We started treatment for possible rheumatoid arthritis, but later on … we were pretty confident that it wasn’t rheumatoid arthritis.” Participants also demonstrated varying degrees of identification with the patient role; students diagnosed before their medical training tended to offer more reflections on themselves as patients. These reflections were also related to experiences of stigma, which were more common among students who disclosed a mental health condition.

Identity compartmentalization

We use the term “identity compartmentalization” to describe the ways in which participants read their patient and student identities as more or less salient depending on context. Identity compartmentalization is a concept from social identity complexity theory, which describes ways in which individuals structure their own perceptions of their multiple group identities. Social identity complexity theory is analytically useful in discursive approaches to identity construction.31,42 In our study, identity compartmentalization was visible when participants saw their patient identity become salient in training settings: These moments reflected challenges to compartmentalizing their multiple identities, since their patient identities “seeped through” into contexts where they performed as trainees. These moments, for example, occurred in preclerkship lectures or seminars in which students experienced strong emotional reactions to hearing their own condition discussed as a medicalized disease rather than an experienced illness. In these scenarios, participants described feelings of alienation from their peers; they felt othered because of their patient identity. Challenges to identity compartmentalization also occurred, for example, in clinical placements when participants discussed difficulties taking on a provider role in scenarios that triggered memories of their patient experience. As one clerk with self-reported physical and mental health conditions described:

At the very beginning I struggled a lot with the physical exams.… I really struggled to approach that confidently and I would ask people, “Is it okay if I touch your neck, is it okay if I do this?” And the teachers were like, “You can’t ask consent for everything, some things hurt and you have to be willing to hurt the patient.” And there was a part of me that really struggled with being able to put on that mask and persona and go in and touch a person in a way that I had experienced as being quite violating.

Participants’ expressions of identity compartmentalization reflect expectations around illness within medical school, via the expected academic, clinical, and social roles of students. Thus, they capture students’ observations about the hidden curriculum, how it shapes what students learn, and how it might unintentionally stigmatize students with disabilities.

Identity intersection

Drawing from social identity complexity theory, we use the term “identity intersection” to describe how participants brought together different identities to create an intersectional group membership.31 This was visible in moments when participants discussed their patient role as a benefit to their performance as a student. These moments highlight opportunities in both the formal and hidden curricula that educators may use to reframe experiences with disability as sources of expertise. Most commonly, participants felt they were better communicators in clinical scenarios, given their experiences as patients. Some participants described having personal understanding of loss and suffering, and knowledge of navigating a confusing health care system. Others explained that their patient role had primed them to become advocates for patients and health systems. However, not all participants could attribute their skills specifically to their disability. As one clerk with self-identified physical, psychological, and mental health issues noted, “I don’t think that [being a patient] is necessarily going to make me better at interacting with [patients] than somebody who hasn’t had the experience as a patient, but it certainly doesn’t hurt.” Moreover, some students disclosed that being a patient could at times make it more difficult to empathize with other patients, either because they felt a patient’s complaints were more minor than their own medical issues, or because of personal mental distress during clinical encounters. Taken together, these results point to the nuanced identity negotiations experienced by our participants, and highlight ways in which the patient role can become a site for reflection on medical care.

Discussion

The findings from this study provide evidence from in-depth qualitative interviews, student blogs, and a review of student affairs services and policies at 13 Canadian medical schools. These findings corroborate existing research on the formal and hidden curricula, and how these shape expectations for success in medical education. For example, Wilhelm18 noted that medical students are socialized to believe they must prove themselves emotionally and physically resilient enough to complete their training, after which they have “earned their stripes.” Our study provides further insight into this socialization process, from the perspective of students whose emotional and physical wellness becomes challenged by disability.

Moreover, the discursive themes of the “good student” and “good patient” emerged through participants’ experiences of their dual identities, providing an interpretive juncture for analyzing the written and unwritten rules of medical education in a way that, to our knowledge, has not been addressed comprehensively in previous literature on the hidden curriculum. The themes of the “good student” and “good patient” imposed starkly conflicting demands on individuals who perceived themselves to occupy both roles. The “good student” discourse was driven by expectations of self-sacrifice in the service of academic performance, while the “good patient” was expected to self-manage and prioritize their health. These discourses and associated practices hold important consequences for the way learners experience their training. As Whitehead43 has highlighted, discourses about institutional roles have material effects on medical education—for example, perceptions of what makes a good doctor influence medical school admissions, curriculum design, and the structure of medical education. Similarly, the “good student” discourse holds material implications for curricular content, clinical teaching, and the availability of institutional supports.44–46 The conflicting discourses of student and patient placed participants in a position where it was nearly impossible to perform to the perceived expectations of both roles. Moreover, participants expressed instances of reluctance to disclose their condition to peers or faculty, when they saw their condition as a source of stigma, incompetence, or vulnerability. This echoed previous work on medical students, residents, and staff physicians, who hesitated to disclose a disability over concerns of confidentiality, discrimination, and appearing competent.3,12,13,15,16 These barriers to disclosure also affect how and when trainees seek out accommodations. As Meeks and colleagues1 have highlighted, medical students may hesitate to disclose a disability because they experience scrutiny about accommodations, or about their ability to perform as a trainee. Moreover, they face the intimidating task of disclosing to multiple administrators or teachers in a large hierarchical setting.1

The commonality between the “good student” and “good patient” discourses lies in the demand for self-management to perform those roles. While psychological approaches offer a framework for understanding these behaviors at the individual level, the sociocultural lens we have adopted identifies the broader social and political meanings of these behaviors.22 In other words, both medical education and the health care system place the primary responsibility for self-regulation onto system users—namely, students and patients. As Aubrecht47 concluded, the language of “resilience” promotes self-management and underscores the neoliberal university’s agenda to cut costs by reframing wellness as an individual responsibility rather than an institutional one. This repositioning turns disability into a student’s failure to self-manage and, in turn, fails to address inequalities among students, and how these inequalities may in fact contribute to students’ distress. Our study highlights the need for active measures to ensure institutional support for students with disabilities and, ultimately, to ensure equitable access to medical training for a diverse physician workforce.

Finally, participants demonstrated highly variable and nuanced understandings of how their role as a patient affected their practice as medical learners. These perceived roles were also in flux and affected by contextual factors. However, some commonalities emerged: Students demonstrated strong reactions to the ways in which their medical education taught diseases with which they identified, and students also professed a sense of deepened interest in communication with patients, particularly around the impact of illness on function and quality of life. Their medical training did not seem to hold explicit opportunities for expressing the understanding gained through personal illness, and thus, our work provides an opening for curriculum development to explore ways in which students’ and teachers’ patient experiences may inform teaching on compassionate care.

Limitations of this study include the potential for sampling bias, apparent in the absence of participants who disclosed learning disabilities. According to a recent survey of U.S. medical school accessibility services, the most common disabilities students report to their institutions include ADHD, followed by learning disabilities and mental illness.2 None of the participants in our sample self-identified with ADHD or other diagnosed learning disabilities, which suggests that our sample may not be representative of all students with disabilities. However, given that 20% of participants did not register for accommodations, our sample captured a broader range of experiences, beyond those who seek out institutional support, to understand the entryways and roadblocks to accessing support services in medical school. A further limitation involves the nature of single-individual interviews as data sources, given that two participants noted that this was the first time they were reflecting on certain aspects of their training, and felt they could not yet provide a fully elaborated reflection. A more longitudinal study design involving follow-up interviews with learners through their training would allow for more in-depth responses. Other data sources could also include analysis of anonymous prompted student reflections, which could allow learners to consider their responses over a longer period of time.

This study holds important implications for curriculum design and accessibility services. To address the material effects of disabilities on medical students’ training and personal health, it will be up to institutions to commit to a renewed focus on accessibility services and accommodations. Historically, these services have received little research attention in the health sciences, but the recently formed Coalition for Disability Access in Health Science and Medical Education, founded in the Unites States, seeks to develop best practices and to facilitate access to accommodations for medical students.1

Moreover, our findings highlight a role for faculty development. For students with formative experiences as patients, this study demonstrates that such expertise often went unmentioned and therefore unacknowledged by classmates and teachers. At the level of discourse, Martimianakis and McNaughton20 have highlighted the potential effects of prevailing governing mentalities on approaches to medical teaching and socialization of trainees. Indeed, several authors have noted that transformative faculty development methods based in reflective practice can be very effective, and include considerations of both professional and personal development.48,49 Curricula that draw on students’ and teachers’ prior experiences—including experiences in the patient role—have the potential to combat stigma and discrimination at the level of medical culture.

Overall, research on medical students with disabilities is still relatively untapped. Our understanding of shifting and nuanced identities in medical training would benefit from more longitudinal qualitative designs that understand the socialization process at a more granular level. Moreover, expanding this work to examine the admissions and residency match processes would provide a lens for understanding perceptions of illness, disability, and disclosure among medical school and residency applicants. Future research in this field will ultimately help to build more supportive institutions and a more diverse health care workforce that can better represent the community it serves.10

List 1

Examples of Framing of “Wellness” in Institutional and Student-Created Discourses, From a Multi-University Study of Canadian Medical Students’ Experiences With Disability and Professional Identity Construction, 2016–2017

Institutional discourse:

  • Wellness as a means to peak performance: “This workshop [on Mindfulness and Peak Performance] will provide you with an exciting introduction to the science of mindfulness and its many personal health and professional benefits. Particular attention will be paid to the link between mindfulness practice and achievement of peak performance in stressful, high stakes and high pressure, professional fields such as medicine.”60
  • “Social wellness” as professionalism on social media: “With the understanding that your social contacts and activities play an important role in keeping you grounded and motivated, this section provides some social media guidelines for you as well as suggestions on how to strengthen those bonds and stay involved even during medical school/residency.”61
  • Wellness as a means to minimize distractions from academics: “The Office of Learner Advocacy and Wellness (LAW) looks after issues pertaining to learner health, well-being and advocacy…. Our aim is to ensure that undergraduate learners are not distracted by health or personal matters and are able to perform to the best of their abilities.”62

Student blog discourse:

  • Wellness as a means to increased efficiency: “Close your books once in a while and do something that relaxes you—you’ll feel refreshed and be much more efficient when you get back to work!”63
  • Wellness as coping with academic challenge: “With the start of a new semester, the changes accompanying the unfamiliar workload and the demands of multiple responsibilities might make taking time for yourself seem less of a priority. But it’s important to remember that practising self care gives you the physical and emotional energy to deal with the challenges you might face.”64
  • Wellness as a competition: “The CFMS [Canadian Federation of Medical Students] National Wellness Challenge is a month long program targeted at building resiliency by fostering positive habits in the daily activities of medical students. In teams, participants completed challenges focused on a different pillar of wellness each week—nutritional, mental, physical and social-academic balance.”65

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