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Using a Diagnostic OSCE to Discern Deficit From Disability in Struggling Students

Patwari, Rahul MD; Ferro-Lusk, Marie MBA, MSW, LSW; Finley, Ellenkate; Meeks, Lisa M. PhD

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doi: 10.1097/ACM.0000000000003421
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Abstract

Problem

The number of medical students with disabilities is rising.1 These students face novel barriers in the clinical portion of their curriculum that can result in poor performance when students’ disability-related needs are unaccommodated or underacccommodated.2 Federal laws governing the inclusion of qualified medical students require a robust interactive process whereby the school engages with the student, disability experts, and faculty to determine reasonable accommodations.3,4 Clerkship directors and preceptors, lacking expertise in the provision of reasonable clinical accommodations, may fail to engage in this process and ascribe poor performance to the students’ disability. The unexamined attribution of poor performance could lead to dismissal and a presumption that the student cannot meet program competencies. Conversely, programs may “fail to fail” a student motivated by fear of litigation resulting in unprepared students in the clinical setting.5

Reasonable accommodations are designed to remove a barrier in the environment. A student’s performance can be fairly evaluated only after a robust interactive process to determine then implement reasonable accommodation to remove these barriers. When concerns about performance occur in the context of disability, faculty may be unable to identify the origin of poor performance in the absence of a disability-informed assessment. When students with disabilities underperform despite the provision of accommodation, medical educators must take additional steps to determine the root cause: identification of students’ academic or clinical deficits resulting in appropriate remediation, revision of accommodations and referral to appropriate services (e.g., counseling, learning specialist), or both. The information gathered during this evaluation can also be used to support a decision to dismiss a student when no further reasonable accommodation can be identified or when the student’s deficit is not disability related. Distinguishing the root cause of failure in a student with a disability has not previously been addressed in the literature, and no disability-specific guidance exists on the topic. A disability-informed model for evaluating student performance allows schools to address failures through a systematic, objective, and informed process, ensuring programs meet their legal obligation for engaging in an interactive process, while providing the highest level of student support to identify appropriate remediation or additional accommodation needs. This educational case study reviews the experience of a Midwestern medical school addressing the poor performance of a third-year medical student with a visual disability during required clinical rotations.

Approach

History of accommodation

Preclerkship didactics and Step 1.

Upon application to medical school, the student submitted disability documentation to the school supporting classroom and testing accommodations. The student successfully completed the first 2 years of medical school and passed the United States Medical Licensing Examination Step 1 exam, with accommodations. Accommodations for coursework included extra time on examinations and enlarged font on written materials. Accommodations for Step 1 included double time over 2 days and permission to use a magnifier during the exam. At home, the student used a closed-circuit television to magnify the screen and enhance contrast.

The student did not engage with technology that read materials aloud and did not use dictation software, noting that these were not productive mechanisms to address barriers caused by the student’s visual decline.

Clinical setting.

In the student’s first clerkship, the student struggled significantly with clinical duties. Despite subpar performance, the clerkship director did not issue a failing grade, partly uncertain of the legal repercussions involved in working with a disabled student. In the second clerkship, the student maintained accommodations and a modified schedule (doubled clerkship length via half-days). Despite these additions, the student continued to struggle with lengthy and disorganized patient evaluations and the inability to complete daily progress notes. Though faculty verbally expressed concern that the student had significant clinical difficulties, failure to articulate these concerns in any formal feedback led to a calculated passing grade. At this stage of the clinical year, the student requested extended time to complete all subsequent clerkship duties. The student entered the third clerkship with the accumulated accommodations but immediately reported feeling overwhelmed, unable to meet the multiple demands of the clerkship, and withdrew after the first day.

From the student’s perspective, the difficulties were disability related and due to an inaccessible environment (e.g., access to electronic health records, note taking). These deficits, the student posited, were barriers to researching patient cases and documenting patient interaction. The student also reported that the student’s patient interactions were meeting or exceeding competency. Faculty suspected knowledge and clinical reasoning deficits prevented the student from successfully completing assigned duties (see Chart 1).

Chart 1
Chart 1:
Student and Faculty Perceptions of the Student’s Difficulty Completing Assigned Duties With Accommodations for a Visual Disability During an Internal Medicine Clerkship at a Large Midwestern Medical School

Ultimately, the student’s case was reviewed by the Committee on Student Evaluation and Promotion. The committee considered failure and dismissal but determined that more information was needed regarding the impact of disability on the student’s performance and whether or not additional accommodations or technology might improve access for the student. At this time, faculty met with the disability liaison to further investigate the competing reports and to determine the origin of difficulty.

Intervention

Hauer and colleagues identified a 3-step model in the remediation of students with difficulties in clinical skill assessments: diagnose, remediate, and retest.6 Building on this work, we propose a diagnostic model of remediation for students with disabilities (see Figure 1). Using a coordinated approach, a “team” was assembled consisting of the assistant dean for clinical curriculum, an outside disability consultant specializing in medical education, the institutional disability professional (a trained individual who evaluates disability requests and determines reasonable accommodations), and the manager of simulation education to design a diagnostic objective structured clinical examination (OSCE) to parse out the root cause of the student’s difficulties.

Figure 1
Figure 1:
Diagnostic model of remediation for students with disabilities. Learners with disabilities who fail to meet a milestone or competency first take a diagnostic OSCE to identify the source of the learner’s difficulty. If a disability-related issue is identified, the student’s accommodations are revised to address this. If a knowledge or clinical skills deficiency is discovered, the student receives academic remediation (as would other students). The student is given opportunities to practice after remedial activities and new accommodations have been applied, then retested with another diagnostic OSCE. If the student has another academic failure, the school’s failure on remediation plan is pursued. If the failure is disability related, new accommodations are explored. If new accommodations are available, these are applied and the student retested. If none are feasible, the student’s qualifications to continue in the program are investigated. Abbreviation: OSCE, objective structured clinical examination.

The team assessed the student’s clinical skills and utilization of accommodations in a simulated environment using standardized patients. The use of a simulation lab was ideal for controlling the environment and cases. This allowed the team to better determine disability-related barriers and quickly and iteratively add and evaluate the efficacy of new accommodations. Using the established rubric for the OSCE, the assistant dean of the clinical curriculum assessed the student’s clinical skills, while the disability professionals evaluated the disability-related barriers and need for additional accommodation. The OSCE contained 3 cases, including a complete history and physical, a focused history and physical, and a targeted communication challenge.

Diagnostic OSCEs

In the first diagnostic OSCE, the student was given a case that would require minimal visual input. The previous accommodations from the clinical placement were retained, including extra time to document patient interaction and enlarged fonts on written materials. Evaluators noted that the student spent a disproportionate amount of time taking notes during the patient encounter, to the detriment of engaging with the patient. The student was unable to formulate an appropriate initial differential diagnosis. Following the patient interaction, the student was unable to complete notes in the allotted time. The student’s communication skills were scored as adequate across all evaluators. Ultimately, the student was unable to complete the diagnostic OSCE successfully with both clinical skills–related and disability-related barriers identified.

Academic remediation following the first OSCE included coaching on clinical reasoning skills with a focus on using an organized approach to information gathering and developing a differential diagnosis to guide the evaluation. The student participated in a series of observed standardized patient encounters. Within and after each, the assistant dean for clinical curriculum provided coaching on which cues were important as well as forming and prioritizing a differential diagnosis from this information. The faculty also modeled these clinical reasoning skills and allowed the student to ask questions.

The diagnostic OSCE revealed some additional disability-related barriers that could be removed through accommodation, for example, the use of a scribe during patient interactions. The student was given the opportunity to practice the new clinical skills and use new accommodations (i.e., the scribe), integrating the feedback from the academic remediation into the student’s approach to the patient encounter.

The student was reevaluated with another diagnostic OSCE with the new accommodations in place. During this OSCE, the student continued having difficulty organizing the evaluation, forming a differential diagnosis, and verbally presenting a structured summary of the encounter. The student had no difficulty taking notes via the scribe, interacting with the medical record via the scribe, or interacting with standardized patients. No new accommodations were identified.

During a debrief of the process, the promotions committee discussed the final evaluations with the student. With the new accommodations, it was determined that the disability was no longer a barrier in the clinical setting and the student concurred. The root cause of the difficulty was ultimately identified as a fundamental lack of knowledge and clinical reasoning skills. Following the debrief, the student opted to withdraw from medical school and enter a master’s in public health program.

Outcomes

The outcome of this process was refined for use in future cases where distinguishing between disability and other causes of deficit is needed. This diagnostic model for evaluating remediation needs of a student with a disability is important as the remediation for clinical skills–related failures is quite different from remediation for disability-related failures, and the impact of disability on the respective settings may be very different. Clinical skills–related failure requires academic remediation, while disability-related failure requires a full exploration of barriers, reasonable accommodations, and assistive technology that may reasonably remove these barriers, allowing the student full access to the clinical setting and the ability to be properly evaluated. While the need for additional accommodations was identified in our educational case, implementing them proved insufficient to bring the student’s performance up to a passing level given the primary sources of deficit: fundamental lack of knowledge and clinical reasoning skills.

This model has the potential to equalize assessment for students with disability who are also unable to meet the level of competency or the passing level by ensuring that disability-related barriers are identified. Implementing the diagnostic OSCE (including both clinical faculty and a disability professional evaluator) for a student with disability also ensures compliance with disability-related laws and exhibits a robust, good-faith effort that is both student informed and student centered. This technique, while piloted on a student with visual disabilities, has utility for all categories of disability as the simulated environment can create unlimited scenarios that directly address the student’s disability-related barriers. In this model, clinical faculty can assess whether a student meets the minimum passing level and the disability experts can ensure that the student has the necessary accommodations to remove barriers.

Students who successfully complete a diagnostic OSCE can return to the clinical environment with new accommodations. Those who are unable to pass with appropriate and comprehensive accommodations may be considered as failing on a remedial plan. Proactively addressing disability needs using a diagnostic OSCE before students entering the clinical year may also prove beneficial in identifying unknown barriers for students with disabilities.

Next Steps

Pass/fail decisions in students with disabilities are made by clinical faculty who have little training in disability assessment, yet they have a duty to ensure that all students, regardless of disability status, meet the baseline clinical skills needed to practice. When a failure is identified, the disability-informed diagnostic OSCE, which uses a team approach, can successfully parse out the causes for failure. Disability-related causes must be met with a reevaluation of accommodations when appropriate and reasonable. Once these are addressed, the student is allowed to pass or fail on level footing equal to those students without disabilities. The next step is to formalize this process to ensure appropriate evaluation of students with disabilities. Faculty should be comfortable that their decision to fail a student with a disability does not mean that the student is dismissed from medical school, but that the student will undergo a disability-informed assessment as to the adequacy of the student’s accommodations for the environment. Faculty should understand that accommodations will be reevaluated based on the various clinical environments, as the previously identified accommodations may be insufficient when a student enters a new rotation with new responsibilities.

Ensuring a thoughtful, disability-informed process is critical for determining the root cause of failure. This action will provide faculty with the confidence to make decisions about the student’s performance knowing that all disability-related barriers have been removed.

References

1. Meeks LM, Case B, Herzer K, Plegue M, Swenor BK. Change in prevalence of disabilities and accommodation practices among US medical schools, 2016 vs 2019. JAMA. 2019;322:2022–2024.
2. Meeks LM, Jain NR. Accessibility, Action, and Inclusion in Medical Education: Lived Experiences of Learners and Physicians with Disabilities. Washington, DC: Association of American Medical Colleges. https://store.aamc.org/accessibility-inclusion-and-action-in-medical-education-lived-experiences-of-learners-and-physicians-with-disabilities.html. Published March 2018. Accessed April 1, 2020.
3. . Americans with Disabilities Act, 42 USC §12101, et seq (1990).
4. . Section 504 of the Rehabilitation Act. 29 USC §701 (1973).
5. Ellaway RH, Chou CL, Kalet AL. Situating remediation: Accommodating success and failure in medical education systems. Acad Med. 2018;93:391–398.
6. Hauer KE, Teherani A, Irby DM, Kerr KM, O’Sullivan PS. Approaches to medical student remediation after a comprehensive clinical skills examination. Med Educ. 2008;42:104–112.
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