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Leading Practices and Future Directions for Technical Standards in Medical Education

Kezar, Laura B. MD; Kirschner, Kristi L. MD; Clinchot, Daniel M. MD; Laird-Metke, Elisa JD; Zazove, Philip MD; Curry, Raymond H. MD

Author Information
doi: 10.1097/ACM.0000000000002517

Abstract

The term technical standards (TS) comes from the Rehabilitation Act of 1973 (Section 504), which defined a qualified individual as someone “who meets the academic and technical standards requisite to admission or participation in the [school’s] education program or activity.…”1 Guidance from the federal government regarding this regulation states, “The term ‘technical standards’ refers to all nonacademic admissions criteria that are essential to participation in the program in question.”2 For example, TS include interpersonal skills and professional attitudes and behaviors. TS are distinct from essential functions, which are the job duties that employed individuals must be able to perform, and from learning outcomes, which are the information and skills that students should learn during their education.

The Association of American Medical Colleges (AAMC) first issued TS guidelines in 1979.3 A white paper, sponsored by the Association of Academic Physiatrists (AAP) in 1993, updated the AAMC’s guidelines and provided additional recommendations regarding their implementation.4 More than 25 years later, though, the AAMC TS guidelines remain the primary point of reference for most related policies. Although subsequent AAMC publications5–8 have provided additional guidance for medical schools to comply with evolving legal and regulatory expectations, the underlying principles guiding schools in the construction of their TS have not been revisited. The Liaison Committee on Medical Education (LCME) and the American Osteopathic Association (AOA) require medical schools both to create TS that are consistent with their mission and to publicize those TS in accordance with applicable law. The LCME’s TS definition9 is based on the 1979 AAMC guidelines, whereas the AOA does not specify the content required in TS.10 As a result, TS language and implementation vary considerably among schools.11 Many TS may not be compliant with Americans with Disabilities Act (ADA) standards because they are vaguely articulated, rely on outdated language and concepts, and/or are not clearly presented in the schools’ admissions materials or websites.12

Given this history, along with the many changes in medical education, medical practice, and the medico-legal landscape in the last quarter century, the AAP commissioned one of us (L.B.K.) to convene an expert task force to revisit their 1993 consensus recommendations. The task force consisted of disability experts, medical education leaders, and disability service professionals who have been engaged in responding to these changes. In this article, we, as members of the task force, propose substantive updates to the 1979 AAMC and 1993 AAP TS guidelines for medical education. Our proposed updates take into account the many legal, cultural, and technological advances that have afforded greater opportunities for people with disabilities and highlight recent changes in some schools’ TS to facilitate the inclusion of students with disabilities.

The Need for Updated TS

Despite some progress in the integration of people with disabilities into professional employment settings since the implementation of the ADA and Section 504 of the Rehabilitation Act, people with disabilities remain substantially underrepresented in medicine. Of the noninstitutionalized U.S. population aged 18 to 24, approximately 3.5% have a physical or sensory disability,13 and up to 10% have some type of disability.14 Estimates of the prevalence of disabilities among medical students are much lower, ranging from 0.6%, an estimate that includes students with physical or sensory disabilities,15 to 2.7%, an estimate that also includes students with learning and psychological disabilities.16 Internal and external factors may contribute to the underrepresentation of these students in medical education, including lack of access to appropriate accommodation at any point in the educational pipeline; lack of knowledge about accommodation strategies; concerns about the cost of accommodations to the institution; stigma, particularly surrounding physical and mental health disabilities17; bias and discrimination in the admissions process and the medical community at large18; and other barriers, real or imagined, regarding the ability of people with disabilities to function as physicians.19 Most likely, a combination of these factors is at play.

The ADA transformed many areas of society; curb cuts, ramps, designated parking spaces, and closed captioning are now accepted parts of American culture.20 Universal design is more commonplace as well (i.e., “the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design”21). Despite these changes, health care institutions still have unacceptably high rates of inaccessible environments and discriminatory practices, as reports of significant ongoing health care barriers show even long after the passage of the ADA.22–24

Revising TS, in and of itself, will not remove these barriers to inclusion, but inattention to how TS play out in practice has clearly impeded progress. Outdated TS can, paradoxically, serve as a barrier to entry to the medical profession for people with disabilities. On reviewing these standards, potential applicants may incorrectly assume that their disabilities preclude them from matriculating, which may inhibit their desire to apply at all. Further, many current TS do not support reasonable accommodations as intended by the ADA,12 and students with disabilities have had to resort to the courts to require compliance from schools, as we describe below. In addition to improving equity and inclusion, updating TS to reflect the current climate would keep schools aligned with evolving social constructs and bring their TS in line with actual practice.

Some health professions schools have adopted a “functional” approach to TS, promoting inclusivity by emphasizing candidates’ abilities rather than their limitations.25,26 (We use the term candidates to refer to applicants to medical school as well as current medical students who are candidates for the MD degree.) Functional TS focus on what needs to be accomplished rather than how it must be done. These standards allow students to use accommodations and permit the ongoing incorporation of technological and medical advances as they become available. Functional TS describe the skills that students must master (e.g., assessment of patients’ functioning, effective communication with patients and the care team) but not the manner in which students must achieve them (e.g., using vision, hearing, speech). In contrast, many traditional TS (termed “organic” TS) are informed by the 1979 AAMC standards and focus on candidates’ innate sensory, physical, and mental abilities instead of their ability to achieve the tasks at hand. Of note, the potential use of intermediaries to accomplish tasks is difficult to address using organic TS. In the most restrictive cases, organic TS require students with disabilities to demonstrate specific physical or mental capabilities without technology (i.e., to hear and communicate orally without the use of hearing aids).27

Changes in the Legal and Regulatory Climate

Although federal civil rights laws mandating equal access for people with disabilities have existed since 1973 with the passage of the Rehabilitation Act, in 1990 the ADA expanded schools’ obligations to provide access and accommodations to people with disabilities. In response to years of court decisions that gradually narrowed the scope of the law, the ADA was amended in 2008 to specify and expand on who is considered “disabled.”28 As disability rights statutes and regulations have steadily progressed, so have the courts’ interpretations of those laws.

In 1979, the first legal challenge regarding disability accommodations, Southeastern Community College v. Davis, reached the U.S. Supreme Court.29 The court upheld a nursing school’s decision to refuse admission to a student with significant hearing loss, deferring to the school’s TS that a student must be able to hear to qualify for enrollment. In its decision, however, the court explicitly acknowledged a future where technological advances could trigger greater obligations for institutions of higher education to admit students with disabilities. This future envisioned by the Supreme Court nearly four decades ago has indeed come to pass. For example, individuals with hearing disabilities now have instant access to auditory information not only in the classroom but also in clinical and surgical settings.30,31 Real-time captioning, smartphones and tablets, remote interpreters through video relay services, and digital stethoscopes can access and monitor data previously accessible only via hearing. Today, subspecialist interpreters are trained to support both providers and patients in the health care environment.27 New tools and technological innovations similarly have opened doors for those with limited vision and other types of disabilities.

This new reality is reflected in recent court decisions. In direct contrast to the 1979 Southeastern Community College v. Davis case, the majority of decisions since 2013 have mandated that schools admit and provide accommodations for students with disabilities, particularly for students with sensory disabilities. There has not been complete uniformity, however, as at least one case, McCulley v. University of Kansas School of Medicine, held that a school did not need to admit a student with physical disabilities.32 Although cost is sometimes cited by schools as a limitation to providing disability accommodations, a university’s entire budget must be considered, which usually renders the concern moot.33

In light of the numerous cases that found rigid, organic TS discriminatory, we believe that schools that rely on the McCulley v. University of Kansas decision to defend their use of organic TS do so at their peril. Alternatively, schools that create functional TS are more closely aligned with the intent of federal disability rights laws.

Table 1 provides a summary of the key legal decisions that informed our task force’s work.

Table 1
Table 1:
Summary of Recent U.S. Case Law Regarding Technical Standards (TS) and Accommodations for People With Disabilities

Changes in Medical Practice

Twenty-first century medicine employs far fewer solo practitioners and places greater emphasis on team-based care, interprofessional practice, information and health care systems, and quality and safety practices. Physician assistants and nurse practitioners are increasingly partnering with physicians to gather and interpret data.34 A wide range of technological advances have armed clinicians with new tools for diagnosis and treatment; some, like telehealth applications, may obviate the need for the physical presence of a clinician. Specialties and subspecialties are becoming more clearly divided between those that are “cognitive” and those that are “procedural”; many physicians’ routine work involves little or no need to perform procedures or even physical examinations.

Moreover, studies demonstrate that proficiency is tied to the frequency with which a procedure is performed. In addition, many practicing physicians are performing fewer types of procedures, while those who do perform procedures acquired their skills during specialty training rather than in medical school. In a 2004 American College of Physicians survey, general internists reported routinely performing only half as many types of procedures as they did in 1986 (from 16 to 7).35 In addition, the increasing use of “procedure teams” in hospitals and advances in interventional radiology have been shown to improve the safety and quality of care.36

Changes in Medical Education

Just as medical practice is embracing the concepts of team-based care and information management skills, medical educators are focusing more on students’ ability to function effectively as part of a team, and they are becoming more interested in students’ problem-solving skills than their factual memory or procedural skills. The rise of competency-based medical education37,38 has helped drive these changes, broadening the aims of medical education to include teaching professionalism, practice-based learning and improvement, and systems-based practice, and shifting the focus of assessment to measuring performance rather than knowledge alone. The AAMC’s Admissions Initiative applied this concept to premedical education as well.39 With this approach, schools can assess the performance of students with disabilities using reasonable accommodations, allowing students to demonstrate their mastery of skills through alternative methods. Some schools have integrated their TS into their competencies, a process that highlights the outcomes themselves rather than the method for achieving them.40

Even new competency-based approaches, however, do not fully integrate disability accommodations. One of the AAMC’s 13 Core Entrustable Professional Activities (EPAs) for Entering Residency focuses on a procedural competency: “All physicians need to demonstrate competency in performing (emphasis added) a few core procedures … basic cardiopulmonary resuscitation (CPR), bag and mask ventilation, venipuncture, inserting an intravenous line” (EPA 12).41 The need to perform these procedures even in residency is questionable, as specialty boards do allow programs to waive the requirement for proficiency in performing specific procedures as a reasonable accommodation for residents with disabilities.42 In addition, one of the AAMC’s proposed admissions competencies champions applicants’ ability to recognize barriers to communication and to adjust their approach, but it also requires applicants to use “spoken words and sentences,” effectively excluding users of American Sign Language or those with other speech-related disabilities who do not rely on their voices. Just as assistive technologies have become increasingly available43 and TS have evolved, so too should the scope of skills that learners must demonstrate as EPAs.

Approaches to Revising TS

The 1979 AAMC TS guidelines require that candidates demonstrate skills including observation; communication; motor function; conceptual, integrative, and quantitative thinking; and appropriate behavioral and social attributes. They also require that medical students be able to perform these actions independently. The LCME uses this TS construct in the glossary of terms that accompanies its current accreditation standards.9 The LCME’s glossary is, however, meant as a guideline; schools already have the flexibility to vary their approach, within the bounds of applicable law.44

The original AAMC TS guidelines accepted technological compensation for disabilities but not human assistance, stating that an intermediary might impose “someone else’s power of selection and observation” on a student’s judgment.3 Many education leaders, including many from the AAP, disagree with this argument and believe that the ADA mandates a rethinking of this position.45–48 Michael Reichgott,46 in a published adaptation of his 1995 AAP-sponsored address at the AAMC annual meeting, asked, “Is the hands-on, personal touching experience … necessary for the effective integration of basic science knowledge and the understanding of pathophysiology?” He noted, “If a trained assistant does the physical examination and provides data to the student (or resident), does this really impose a negative ‘interpreter’ effect?” The 2010 AAMC publication Medical Students With Disabilities: Resources to Enhance Accessibility included a specific discussion of intermediaries playing a role in data gathering:

Certain parts of the exam may not be physically possible for the student and may require the use of peers or physician extenders.… It may be necessary to modify the requirement for manual tasks, to emphasize cognitive aspects (recognition of abnormal findings and development of differential diagnosis and treatment plan) rather than the ability to perform the task itself.8

Although many schools were already permitting language intermediaries (interpreters) for students with hearing or speech disabilities, this language from the AAMC signaled a new opportunity to explore the use of physical intermediaries for data collection. A number of medical schools now provide a paid staff intermediary who can assist students with physical disabilities.49,50 Of note, functional TS allow a student to “direct” another individual, while organic TS do not.

Recommendations

To allow for accommodations like those we discussed above, we propose two functional approaches to revising TS that schools may adopt, depending on which best meets their needs. In the first model, shown in Appendix 1, we propose new language for TS using the five functional categories initially proposed by Reichgott.46 Changing the TS categories allows for a sharper focus on “what” students must demonstrate rather than on “how” they must demonstrate it. Many of the skills in Appendix 1 are essentially the same as those in the AAMC groupings. The second model, shown in Appendix 2, retains the TS categories originally set forth by the AAMC,3 which defined some skills based on the physical attributes of candidates, but it updates the content to promote a functional, rather than organic, approach. By allowing candidates to “provide or direct” medical care, both models allow for the use of intermediaries when appropriate.

We also offer the following recommendations, intended as an update of the 1993 AAP guidelines. The goal of these recommendations is to address the call to action, from a number of groups including the AAMC, for enhanced accessibility for students with disabilities and for the further promotion of a diverse physician workforce.8,13,17,51–54

We recommend that medical schools:

  1. Include students with disabilities as part of their commitment to diversity and inclusion and monitor admission and retention data in a manner that is sensitive to the privacy and preferences of these students.
  2. Critically review and update their TS, taking into account the substantial evolution of the role of the physician in clinical care, the potential for new technologies to provide reasonable accommodation for an increasingly broad range of disabling conditions, and recent changes in legal and regulatory expectations for schools to be more accommodating.
  3. Use a functional rather than organic approach to writing TS. See Appendix 1 and 2 for two approaches that meet current legal standards and allow schools and students appropriate flexibility.
  4. Correlate or integrate the expectations of their TS with the core competencies and/or EPAs expected of all students.
  5. Review and ensure the accessibility of their TS to applicants, students, and the public via their website. These communications should both clearly state that the school accepts qualified students with disabilities and delineate the criteria all students must meet to be admitted and continue in the school.
  6. Clearly define procedures for requesting accommodations, which must be appropriately confidential and individualized, and readily available on websites and in admissions materials, student handbooks, syllabi, and other resources routinely used by students. See Supplemental Digital Appendix 1 (available at http://links.lww.com/ACADMED/A612) for detailed recommendations about the accommodations process.
  7. Ensure that the process of making decisions about accommodations is interactive and actively includes the student with the disability and an individual with expertise in disability accommodations and ADA requirements who is not in a position to evaluate the student. This process should be ongoing to address evolving needs throughout the student’s education.
  8. Implement the principles of universal design in education55 by creating instructional goals, methods, materials, and assessments that work for all learners, to the greatest extent possible, without the need for after-the-fact disability accommodations to make them accessible to students with disabilities.

Future Directions

As medical education leaders have articulated for more than two decades, people with disabilities bring unique perspectives to medicine and help create a diverse physician workforce made up of culturally competent practitioners who can meet the needs of their patients and educate their peers. Sponsoring and accrediting agencies must expand their review of and heighten expectations for medical education programs with respect to the inclusion of people with disabilities and programs’ adherence to the ADA and Section 504 of the Rehabilitation Act. Doing so will require modifications to current data tracking systems to include questions about disability status on standard surveys and questionnaires. Additionally, for students with disabilities who are unable to do the physical work of medicine themselves, the profession should address the appropriate use of intermediaries in collecting data and performing elements of the physical examination. We also advocate for further research into the barriers that impede people with disabilities in the medical education pipeline, patient perceptions and outcomes when they receive care from students and physicians with disabilities, and the use of both human and technological intermediaries to advance the inclusion of people with disabilities in medical education. We anticipate that the emerging focus on universal design and competency-based medical education will eventually render TS obsolete. In the meantime, the prevailing approach to TS must be revised.

Appendix 1 A Functional Model for Revised Technical Standards (TS) for MD and DO Medical Education Programs, Using Michael Reichgott’s Categories46

[School name] seeks to produce highly skilled and compassionate doctors. Students are expected to develop a robust medical knowledge base and the requisite clinical skills, with the ability to appropriately apply their knowledge and skills, effectively interpret information, and contribute to patient-centered decisions across a broad spectrum of medical situations and settings. The following technical standards, in conjunction with the academic standards, are requirements for admission, promotion, and graduation. The term “candidate” refers to candidates for admission to medical school as well as current medical students who are candidates for retention, promotion, or graduation. These requirements may be achieved with or without reasonable accommodations. Candidates with disabilities are encouraged to contact [disability office or position] early in the application process to begin a confidential conversation about what accommodations they may need to meet these standards. Fulfillment of the technical standards for graduation from medical school does not guarantee that a graduate will be able to fulfill the technical requirements of any specific residency program.

Appendix 2 A Functional Model for Revised Technical Standards (TS) for MD and DO Medical Education Programs, Using the Association of American Medical Colleges’ Categories3

[School name] seeks to produce highly skilled and compassionate doctors. Students are expected to develop a robust medical knowledge base and the requisite clinical skills, with the ability to appropriately apply their knowledge and skills, effectively interpret information, and contribute to patient-centered decisions across a broad spectrum of medical situations and settings. The following technical standards, in conjunction with the academic standards, are requirements for admission, promotion, and graduation. The term “candidate” refers to candidates for admission to medical school as well as current medical students who are candidates for retention, promotion, or graduation. These requirements may be achieved with or without reasonable accommodations. Candidates with disabilities are encouraged to contact [disability office or position] early in the application process to begin a confidential conversation about what accommodations they may need to meet these standards. Fulfillment of the technical standards for graduation from medical school does not guarantee that a graduate will be able to fulfill the technical requirements of any specific residency program.

Acknowledgments: The authors thank Danielle Powell, MD, MSPH, and Joan Bisagno, PhD, for their contributions to the task force.

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