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You Belong in the Room

Addressing the Underrepresentation of Physicians With Physical Disabilities

Schwarz, Charlotte M., MD; Zetkulic, Marygrace, MD

doi: 10.1097/ACM.0000000000002435
Invited Commentaries
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In this Invited Commentary, the authors use personal experiences to highlight how obstacles for qualified candidates with physical disabilities persist in medical education, especially at entry to and early stages of training. In an era when medical schools and residency programs advocate principles of diversity and inclusion, it is estimated that medical students with physical disabilities still comprise less than 1% of learners. The authors present four constructive actions to address the underrepresentation of individuals with physical disabilities in medical schools: (1) acknowledging biases, (2) building networks, (3) reassessing the undifferentiated model of medical education, and (4) advocating the advantages of physicians with disabilities. Supporting trainees and practicing physicians with physical disabilities requires pragmatic evaluation of the essential functions of contemporary medical education, as well as lateral thinking to approach clinical work in innovative ways.

C.M. Schwarz was a medical student, Semmelweis University, Budapest, Hungary, at the time this was written. She is now a first-year resident, Duke University, Durham, North Carolina.

M. Zetkulic is assistant professor of medicine and program director, Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Charlotte M. Schwarz, DUMC Box 3837, Durham, NC 27710; e-mail: charlotte.schwarz@duke.edu.

Nothing disrupts the streamlined movements of bedside rounding like the threat of my wheelchair running over someone’s foot. A few weeks into my clinical rotations, while still learning to maneuver on the floors, I (C.M.S.) found myself apologizing repeatedly as our team took their places in a particularly crowded patient room. A classmate’s comment has remained with me: “There’s no need to say you’re sorry. You belong in this room too.” Misgivings about “belonging in the room” are pervasive among trainees, but for medical students with physical disabilities, that room seems particularly unreceptive.

Individuals with physical disabilities continue to be disproportionately underrepresented in medical education despite the stated intentions of medical schools to cultivate diversity and compliance with the Americans with Disabilities Act. In an era when medical schools and residency programs advocate principles of diversity and inclusion, it is estimated that medical students with physical disabilities still constitute less than 1% of learners.1–3 This dismal statistic should come as no surprise, but when I embarked on the residency interview process recently, it became an isolating reality. One faculty member said that in his nearly two decades of reviewing applications, I was the second wheelchair user he had encountered. As someone with a visible and significant mobility impairment, I was reminded by an utter lack of representation how privileged I am to have reached this stage of medical training.

Yet physicians with disabilities are practicing and will likely continue to do so in increasing number as assistive technologies advance.4 Compared with medical students, there is a higher percentage of practicing physicians who develop disabilities (estimates range from 2% to 10%), suggesting that the hurdle is entry into medicine.5 Thus, the training experience can and ought to shift from a series of obstacles for learners with disabilities to a supportive process that harnesses the skills of any qualified trainee. Striving for greater inclusion of students with physical disabilities in clinical education introduces perspectives that enrich the medical learning environment. Conversely, the absence of physicians with physical disabilities is particularly pernicious because individuals with physical disabilities interact with the medical community more frequently than others. For patients with disabilities, failure to see themselves represented in the physician population reenforces the false dichotomy of the able-bodied clinician and the disabled patient. Inclusion of students with physical disabilities compels us to examine with fresh eyes the abilities that are essential to serving our patients.

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Acknowledging Biases

The number of medical students with disabilities compared with the number of practicing physicians with disabilities provides evidence that the barrier for students with disabilities is at the entry point to medicine. Why this persists, despite the intention of the Liaison Committee on Medical Education to uphold “technical standards for the admission, retention, and graduation of applicants or medical students in accordance with legal requirements,” is more difficult to address.6 Research examining implicit bias in medical school admissions and health care offers some insight.7 , 8 These studies examine the role that unconscious social judgments play in disparities related to gender, race, and other characteristics that are vulnerable to stereotyping. The specific implicit bias of other health care professionals toward potential trainees with visible disabilities has also been demonstrated.9 , 10 Awareness and open discussion of these biases would redirect attitudes that underestimate the resourcefulness and capabilities of individuals with disabilities. Students with physical disabilities experience this when they are asked how, and even whether, they are able to examine patients. Both have been asked of me since starting medical school, but I have learned to welcome the ensuing conversations because they facilitate the frank discussions I wish had occurred leading up to the admissions process, when advisors and clinicians often met the issue with silence instead.

What complicates matters is that implicit bias coexists with explicit doubt about whether people with physical disabilities have a place in the medical profession. These reservations stem from the dominance of the medical model of disability held by many health care workers, a framework that views an individual’s intrinsic impairments as factors limiting full integration into society.11 , 12 The merit of this model is its biological focus which complements much of medical science; however, because of this, those within the community adopted it as the self-evident and monopolizing perspective.13 By contrast, the social model of disability recognizes how these conditions are fundamentally defined by society’s attitudes and the institutional structures that maintain them. Viewing physicians and physicians-to-be through both of these lenses simultaneously is a formidable task because it challenges fixed assumptions and subjective norms in a tradition-grounded profession. However, in striving to develop an approach encompassing both the medical and social models of disability, medical education institutions can go a long way toward dismantling the socially constructed obstacles that hinder the integration of individuals with disabilities. Achieving a balanced perspective of the medical and social models of disability aligns with medicine’s ethos of innovation to support physical and mental well-being for as many people as possible.

In addition to acknowledging preconceptions, institutions can address another practical barrier to admission by examining their interpretations and implementations of what constitutes reasonable accommodations for inclusive education. Unlike in the classroom, where adaptations for physical disabilities rated as highly desirable were also rated highly feasible, these two variables may seem at odds in the clinical setting.14 For example, renovating the anatomy institute where I studied would have had the highly desirable outcome of allowing students like myself to access the course without transferring to a portable wheelchair, but its feasibility was low because of the expense and protection of the historic building in which the department was housed. Physicians who have developed disabilities after being in practice have innovated to make system modifications that enable them to continue in practice. These modifications should be considered for physicians in training who need them as well.

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Building Networks

Some of the most meaningful connections I have made have been with a handful of other individuals with disabilities who are also pursuing careers in medicine. These people I met through word of mouth were all trainees themselves, not much further along in their education than I was, facing and overcoming struggles similar to my own. Notably, my medical school put me in contact with another student there who used a wheelchair; her advice about the logistics of accessibility smoothed my transition, but it was her presence in the institution that set an invaluable precedent. A few years later, the dean’s office contacted me about speaking with an applicant with mobility impairment. Our collective presence in such a short time span speaks to the way in which the acceptance and admission of students with physical disabilities can act in a positive feedback loop. Ideally, pipeline programs at the high school and undergraduate levels would set changes in motion that allow students with physical disabilities to learn from more experienced clinicians who face relatable challenges.

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Reassessing the Undifferentiated Model of Medical Education

From speaking with members of the medical community and looking back at the first phase of my medical education, it seems that the largest hurdle preventing individuals with disabilities from admission to medical training is the prevailing belief that a student ought to begin medical education undifferentiated. The “undifferentiated graduate” is one who possesses all of the technical skills required to enter any specialty.3 The Association of American Medical Colleges’ Core Entrustable Professional Activities for Entering Residency (Core EPAs) are the best evidence that this belief prevails amongst even our most progressive educators.15 The Core EPAs provide thoughtful details about the necessary cognitive and communication skills that all students should achieve by the end of medical school; however, examine EPA 12: Perform General Procedures of a Physician. This EPA outlines procedures including basic cardiopulmonary resuscitation, bag-mask ventilation venipuncture, insertion of an intravenous line, and placement of a Foley catheter. These procedures are valuable in some residencies while irrelevant to others. Moreover, most clinical settings have delegated these procedures to ancillary staff, so they are almost never performed by practicing physicians in a wide variety of specialties. In a survey of attending physicians, residents, and medical students, 69.8% disagreed that the “undifferentiated graduate” was a useful construct.3 The contemporary practice of medicine has in actuality made this model outdated and unrealistically stringent for physically disabled students to the point of preclusion.16 What remains is an undue burden on those with disabilities, for whom implicit bias presupposes differentiation where it may not yet exist, and whose nondisabled peers avoid the same scrutiny because their differentiation is credited to arise out of personal inclination.

Graduate specialties that require manual dexterity recognize that the overt absence of physical limitation is insufficient to determine success in their field; such specialties are experimenting with objective measures of dexterity at the time of the residency application process.17 , 18 In light of these efforts, limiting students with disabilities to the broader opportunities of the medical profession is unnecessary. Instead, medical students should be selected on the basis of their potential to develop the cognitive ability to integrate knowledge into sound clinical judgment and develop evidence-based, patient-centered practices. These are skills that are transferrable across all domains of medicine. The Core EPA project has been more successful in identifying and articulating these cognitive and communications skills. By focusing on these EPAs, progress could be made in reevaluating unnecessary barriers, and the unrealistic goal of pluripotent graduates would not be used to disqualify medical students with physical disabilities from the outset.

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Advocating the Advantages of Physicians With Disabilities

Regardless of their specialization, students with disabilities have an inherent understanding of the concerns and challenges of their disabled patients, and their presence fosters an aspect of cultural competence that is lacking in medical education today: In a survey of medical school deans, 61% reported that their graduates were competent to treat patients with disabilities, though 81% of medical students reported no clinical training and expressed inadequate competency to do so.19 I see this in my well-intentioned classmates, the vast majority of whom have never had personal experiences with disabled members of the community. True disability training requires interaction with people with disabilities as peers and colleagues.

These kinds of interactions would also have positive effects for health care of Americans with a disability, over 90% of whom seek health care from community providers.20 Initiatives to incorporate members of this growing minority group in medical education as well as to train nondisabled students about working with this patient population have lagged, even as physicians belonging to minority groups have been shown to be more likely to serve minority and poor populations in a sustained pattern of service.21 Similarly, deaf and hard-of-hearing health professionals are more likely than average to serve deaf and hard-of-hearing patients.22 These advantages may well extend to the training of students with physical disabilities. When these students graduate and select primary care specialties, they can better meet the needs of underserved disabled populations.23

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What’s Next?

Nowadays, the more clinical responsibilities I take on, the more I can rely on being known for the quality of my work rather than the seated position from which I do it. What remains is the conviction that other qualified individuals with physical disabilities can thrive and contribute to this profession. Indeed, medical training institutions espouse the principles that diversity among care providers informs perspectives for impacting broader patient populations, and that it is the capacity for sound clinical reasoning that forms the cornerstone for delivering this care. Moreover, it is generally acknowledged, if tacitly, that everyone is or will be personally affected by some degree of disability. Supporting trainees and practicing physicians with physical disabilities requires a pragmatic evaluation of the essential functions and goals of contemporary medical education, as well as lateral thinking to approach clinical work in innovative ways. We can achieve acceptance not by promoting ideology but, rather, by making systemic changes to create and sustain opportunity for individuals with disabilities to pursue careers in medicine.

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Acknowledgments:

The authors thank Dr. Youmna Sherif for her feedback and support of an earlier conceptualization, and Viola Minicozzi for reliably insightful conversations on this topic.

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