#23 Supporting Learners with Disabilities

October 28, 2022 | By Molly Heublein

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With Dr Lisa Meeks

Lisa Meeks, PhD (UMICH) @meekslisa of Docs with Disabilities Initiative and Podcast shares her expertise around supporting learners with disabilities.  In this episode, we challenge our ableist approach in medicine and focus on including the rich diversity of disabled learners in medical training.  We review best practices for mentoring students, ways institutions can improve disability policies (and follow ACGME guidelines), and so many resources to learn more.  Whether you’re a student, trainee, or faculty member, this episode offers a view into how all of us in health professions education can work to advocate for, support, and empower ourselves and our colleagues with disabilities. 

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ favorite piece of advice 
• Picks of the Week
• Case from Kashlack Memorial
• History of progress toward supporting medical trainees with disabilities
• The importance of language
• Supporting learners with disabilities as part of DEIA 
• Resources for students 
• Accommodations in practice 
• Evaluating residency programs 
• Disclosing disabilities 
• Specifics of accommodations
• Benefits for working with learners with disabilities
• Future outlook on learner disability and accommodations access
• Outro

Supporting Learners with Disabilities Pearls

1. Supporting learners with disabilities is core to our diversity, equity, inclusion, and anti-oppression (DEIA) values.  Training alongside a disabled learner, seeing them as a peer and equal, and working toward a shared goal are the best ways to reduce stereotypes and all forms of discrimination that can carry over to improve patient care.  
2. Institutions should have clearly published GME disability policies, and should follow these policies to allow disabled residents needed accommodations.  Ideally, a trainee should report to a disability resource specialist or at the least a confidential personnel who is not involved in evaluation.
3. Framing of disability is critical and should be done with an strengths-based outlook instead of a problem mindset, shifting to emphasizing the value and potential this learner brings to the institution. 
4. Self-reflection is important! Reflect on your assumptions of disability, are they grounded in evidence, or do they follow common stereotypes?  Challenge yourself to learn more by using some of the resources highlighted below.

Supporting Learners with Disabilities 

History 

The medical profession has traditionally used the medical model of disability to inform how we think about learners with disabilities.  This ableist approach focuses on “fixing” a disability rather than accepting and supporting learners.  

This has been shifting in recent decades, with more advocacy and publications, two in particular:  

• The AAMC 2018 report Accessibility, Inclusion, and Action in Medical Education: Lived Experiences of Learners and Physicians With Disabilities helped redefine how we approach medical trainees with disabilities.
•  ACGME program and institutional requirements of 2018 stated institutions must have disability policies and provide accommodations under those policies. 

Dr. Meeks and her group have done significant research in this arena, expanding beyond the qualitative research that went into the AAMC report to a richer exploration via the Docs with Disabilities Initiative and Podcast which share the stories of what health professionals with disabilities have experienced.  Hearing these stories can help normalize disability.

Dr. Meeks sees a shift in the new generation of post-ADA learners bringing disability pride and a clear understanding of their rights.  As such, educators and institutions are tasked with providing not just the legal threshold of accommodation and an equitable learning environment.  We need to work on creating a just and inclusive workforce, supporting anti-ableism, anti-racism, and anti-oppression values.

Language

The language we use should reflect the preferences of the community.  This can be identity-first, i.e. disabled physician, or person-first language, ie physicians with disabilities.  Dr. Meeks purposefully uses both types of language to include all as disabled individuals may prefer one type of language over the other. 

Supporting Students with Disabilities

Supporting learners with disabilities is core to our efforts in diversity, equity, inclusion, and anti-oppression (DEIA) values.  Most forms of oppression are based in a form of ableism, the belief that a life is less than because of the group you are a part of.  All systems of oppression work together to keep one another down.   None of us are free until we are all free.

Resources for Students 

• Medical Students with Disability & Chronic Illness (MSDCI) is a student lead community of support and sharing of information
• Dr. Meeks’ organization Docs with Disabilities and Podcast is a source of asynchronous mentoring 
• Stanford Medicine Alliance for Disability Equity and Inclusion (SMADIE) has a robust mentorship resource program

Accommodations in Practice

In the best-case scenario, students wanting to access resources around their disability can meet with a disability expert or DRP (Disability Resource Professional) which is unfortunately not available at all institutions.   The trainee should speak with the DRP and program director who can help determine the best accommodations. Once accommodations are agreed upon, a coordinator should communicate with the learning sites about the accommodations. 

Early communication is key to successful implementation of accommodations for learners with disabilities.  Once accommodations are agreed upon, communication with training sites should be top priority. 

Equally important is the way we frame accommodations. In Dr. Meeks’ expert opinion, we need to avoid framing disability with a problem mindset (i.e. there is an issue or problem that needs to be fixed).  Instead of approaching a training site with a problem mindset and saying, “there is a student or resident with a disability that needs accommodations, how do we accommodate them or can we accommodate them?”, we should frame this as an opportunity.  “Let’s together expand our ideas about diversity. Let’s bust stereotypes and change perceptions for our patients and peers through this person training at your site. How amazing is it that you get the opportunity to have this diverse resident or student inform the practice of medicine at your site.” We need to focus on this strength-based communication strategy to support our learners and reframe the conversation in regards to people with disabilities. 

Accommodations should be paid for by the institution training the individual with a disability, not a specific department.  This practice reduces bias because it decreases the chance a program director will consider costs of accommodations when ranking resident trainees.  In reality, this is more often a perceived cost as the majority of accommodations cost little to nothing to implement, typically less than $500 (JAN 2020).

How to evaluate residency programs’ support for disabilities

When a student is considering which residency programs to apply to and which will best support their disability, Dr. Meeks suggests considering:

• How many people are in the program?  What are the coverage policies?
• How can the size of the program affect their accommodations?
• What kind of hours are required?
• Will the learner have a support system around them?
• Is the speciality a good fit for the long term?  

Ideally, some of this counseling should come from someone knowledgeable about disability policies/employment law and specifics of different residency programs while also holding a trusting relationship with the specific student.

Disclosing Disabilities 

The majority of medical trainees with disabilities have an invisible disability (Meeks 2021).  It is a personal choice to disclose during or before the residency match process.  The benefits of sharing include an opportunity to foster honest communication with a program director or other members of the residency program leadership.  Dr. Meeks’ expert opinion is that medical students who disclose their disability are more likely to find residency programs that want them and appreciate their diversity, and therefore the trainees tend to have a more positive residency experience.  Dr. Meeks recommends listeners check out Docs with Disabilities Podcast Episode 30 where Drs. Cron and Meiss discuss disclosure.  In the end, it’s a personal choice, and each person needs to do what they feel comfortable with.  A mentor can help a student consider the pros and cons of disclosing.  Additionally, a  mentor can help make sure the residency specialty milestones and competencies fit with the learner’s abilities and expectations. 

Disabled Trainees bring Value

Training alongside a disabled learner, seeing them as a peer and equal, and working toward a shared goal are the best ways to reduce stereotypes and all forms of discrimination.  We all rely on stereotypes to process information quickly, but by working alongside peers with disabilities daily we erode stereotypes that can carry over to improve patient care.  1 in 4 patients has a disability.  Patients with disabilities have less access to health care, screening, and worse health outcomes (WHO 2021).  

Institutional Policy on Disability Accommodations

In Dr Meeks’ recent paper, as of 2020 a significant number of large institutions did not have clear GME policies on disability (only 68% did) and even more failed to have a clear procedure for disclosing a disability and obtaining accommodations (only 59%) even though this is an ACGME requirement.

Best practices for sharing your institution’s policy include the following (Meeks 2019): 

• Use language that is not based in legal compliance, but instead speaks to this as part of your value system, highlighting the benefits of supporting a diverse workforce
• Make the disability policy easily available.  
• Include a confidential and educated disability specialist if at all possible.  
• Enhance knowledge of the benefits – people with disabilities want to work in primary care (Meeks 2022), students with disabilities are more empathic than their peers, and bring a lot of value (Mogenson 2019, Schwarz 2019). 

Ideally learners should not be disclosing disabilities to supervisors/evaluators.  Programs should work with the GME office to identify a confidential person to report to in Human Resources or occupational health.  

Mentoring/career counseling before application around essential job requirements is essential.  If there are essential job functions that a disabled applicant cannot meet they should reconsider if that program is a right fit.  If a trainee has matched and needs accommodation, Dr. Meeks notes that program directors actually have a lot of latitude to consider flexibility within a program that may allow a resident to do more time at a particular site or rotation that allows more flexibility to fit their needs. 

Resources for Program Directors (and all of us!)

• ACGME Equity Matters– two modules about 25 minutes each – these cover equity/inclusion, legal issues, reasonable accommodations and more resources
• Disability in Graduate Medical Education from Docs with Disabilities (DIGME): a community of practice that shares multiple resources like Just in time one pagers, 5-minute videos on the disability process, and a curated powerpoint for training at your institution about disability inclusion in GME. They also host a list-serv where people can ask questions and get guidance from the community. 
• AAMC 2018 Report Appendix A (page 75) has an amazing checklist/toolbox.

Considering Accommodations for Residents

Ideally, learners with disabilities have had career counseling to determine their unique needs and help fit that with certain programs or specialities ahead of applying to programs.   In medical school, accommodations are easier to provide; in residency, the learner is under employment law, and it is important to consider essential functions of the job-  accommodations may or may not be reasonable.   Going back to open and honest communication can help open up options.  Program directors actually have a lot of latitude in determining requirements within their program which allows perhaps a resident with a disability to spend more time on an outpatient elective or spend more time at a site that has flexible options.  Understanding what has been done in other situations is the first step in considering what can be done: crowdsourcing and thinking outside the box can help.

Ideal Model for Disability Inclusion

Dr Meeks is focused on harm reduction while we move toward an aspirational space for disability inclusion.  Almost 8% of residents have disabilities, less than half ask for accommodations and this can have repercussions (Meeks 2021).  She suggests that we anticipate that people will have disabilities in your program, so we should think about access in all that we do.   Small shifts can improve access for all- build in flexibility with coverage models, caption meeting on zoom, make sure grand rounds is in a location that is accessible.  Be aware of your language when framing cases or on rounds- try not to frame a disability as a fatalist identity.  When you have a learner, think about ways to reduce their barriers.  Self reflection is important-  are assumptions about someone with a disability’s ability to participate in your program based in evidence?   Keep educating yourself, follow established best practices. 

Take home points:

Listen to the Docs with Disabilities podcast- challenge yourself to change how you think about disabilities.  Remember that this could be you- disability is a group that anyone can join.  If you developed a disability would you want to lose your livelihood or would you want your institution to support you.

Links

1. Dr Meeks’ book recommendation: When Things Fall Apart: Heart Advice for Difficult Times by Pema Chodron
2. Era’s pick of the week: Marcel the Shell with Shoes on movie 

Goal

Listeners will appreciate the history of, differential experiences of, and best practices to support learners of varying abilities within health professions education. 

Learning objectives

After listening to this episode listeners will…

1. Recognize the history of health professions’ education interactions with learners with various abilities 
2. List best practices for individuals, teams, and institutions for communicating diversity policies and creating policies for disclosure of disabilities among health professions learners
3. Employ strategies to gain further awareness of possible solutions and skills to implement supportive policies for disability accommodations
4. Describe a disability-informed framework to retain and support providers in a post-pandemic (or intra-pandemic?) world

Disclosures

Dr Meeks reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Meeks L, Heublein M, Kryzhanovskaya E. “#23 Supporting Learners with Disabilities” The Curbsiders Teach Podcast. http://thecurbsiders.com/teach.  October 28, 2022.