Students with disabilities add rich diversity to medical education and help motivate health equity. Unjust obstacles faced by many of these students along pathways to medicine begin during medical school admissions. Deeply embedded ableist notions of what it means to be a physician keep archaic practices in place that serve as systemic barriers to the admission of members of this population. This article summarizes the prominent obstacles for applicants with disabilities and suggests ways in which thoughtful, inclusive admission policies and practices can ultimately contribute to a clinical workforce that is more appropriately diverse and prepared to provide just and patient-centered health care.
Diversity and Disclosure
Physicians of the 21st century need the skills and knowledge that are fostered in diverse learning and work environments.1 Research shows that diversity contributes to creativity and development of problem-solving skills, with more diverse groups outperforming more homogeneous ones,2,3,4 a fact that should influence how we select members of medical school classes. In 2016, 25.7% of the US adult population included persons with a disability.5 Medical students with disabilities, training among diverse faculty and colleagues, would positively contribute to the preparedness of physicians and their colleagues to meet the unique needs of patients with disabilities, facilitate shared decision making, and contribute to innovation—and do so with greater empathy.6,7,8,9,10,11,12,13,14 Despite ongoing inclusion efforts,15 the numbers of medical students16,17,18 and physicians with disabilities remain small,19 and unjust obstacles persist for persons with disabilities looking to matriculate in medical school.20,21,22,23,24,25,26,27,28
This article summarizes prominent obstacles for medical school applicants with disabilities and suggests ways in which thoughtful, inclusive admission policies and practices can ultimately contribute to a clinical workforce that is more appropriately diverse and prepared to provide just and patient-centered health care.
Underrepresented in Medicine
US legal protections for persons with disabilities preclude monitoring progress in inclusive admissions, given the bar on preadmission inquiry into applicants’ disability status.29 A downside to these protections is that monitoring how many medical school applicants with disabilities become matriculants with disabilities is not easy. We can, however, seek to understand the admissions experiences of persons with disabilities through retrospective analyses of school-centered30 and trainee-physician15 research and via commentaries.8,9,10,11,12,13,14,31 While we cannot monitor the number of candidates with disabilities who are accepted to medical school, we can monitor the retention of students with disabilities who matriculate.
Among those who do matriculate, not all will feel safe disclosing their disabilities. An anonymous Association of American Medical Colleges (AAMC) survey of graduating students revealed that 7.6% identified as having a disability,32 yet data collected directly from medical schools show that only 4.6% of students in MD (doctor of medicine) programs and 4.3% of students in DO (doctor of osteopathic medicine) programs disclose their disability to the school and request reasonable accommodations.16,18
The pathway from education to practice is murky, given the dearth of information. One recent study of emergency medicine resident physicians found that 4.1% disclosed a disability and requested accommodation.33 The number attenuates along the pathway from education to practice, with recent data showing that only 3.1% of physicians self-identify as having a disability.19 These data suggest that educational and professional development pathways are fraught with barriers,19,33,34 despite legal protections and reasonable accommodations required under the Americans with Disabilities Act (ADA).35 One might ask: If including individuals with disabilities carries such promising benefits, why are so few individuals with disabilities in medicine? Identifying barriers to their admission to medical school is key.
Ableism Undermines Access
Long before people with disabilities apply to medical school, it’s likely that many of them experienced formal education accompanied by informal lessons on how to navigate disability-related obstacles, such as lack of access to technical and advocacy (including self-advocacy) resources; lack of opportunities to take science, technology, engineering, and mathematics courses; scarcity of role models with disabilities succeeding in hierarchies of science professions19,31,33,34; and historically entrenched systemic ableism reinforced by social, cultural, and interpersonal messaging—implicit or explicit, intentional or unintentional—that disability means inability.23,24,25,26,27,28,36,37 Disabled learners commonly experience ableist bias as stigmatizing and oppressive in their early childhood, adolescent, college, and graduate and professional education encounters; inequitable access to shadowing opportunities38; and high-stakes testing that is burdensome and time-consuming for them, as it requires far more documentation than is required under the law.36,39
If including individuals with disabilities carries such promising benefits, why are so few individuals with disabilities in medicine?
For those who persevere through the application process, new barriers may preclude them from entering medicine, such as the need to disclose disability status and sensitive details about their disability in exchange for access23,36 or technical standards that block their matriculation40,41,42,43,44,45,46,47,48 even if they are highly qualified. In addition to these barriers, many students lack mentors with expertise in effectively advocating for disability-related needs, especially in hierarchical settings with immense power differentials.
Prior to matriculation, many medical schools require students to attest to their ability to meet the school’s technical standards, some of which explicitly forbid use of accommodations, such as intermediaries and interpreters.41 Although technical standards may only be used to disqualify an applicant if they are nondiscriminatory and if no reasonable accommodation would allow an applicant to meet them,42 technical standards have thwarted matriculation (and even the initial decision to apply) of many qualified applicants to many medical schools.40,41,42,43,44,45,46,47,48
Abundant research and commentaries have problematized technical standards as outdated, discriminatory,40,41,42,43,44,45,46,47,48 and unnecessarily geared to patient safety49 in yet another expression of systemic ableism. Some analyses illuminate how medical schools’ technical standards undermine equity44,45 or propose alternatives.40,41 Others offer guidance, exemplars, and resources on how to make inclusive, nondiscriminatory technical standards.46,47,48 For example, one article advises a medical school’s technical standards to (1) make a statement about the school’s valuing disability as an expression of diversity, (2) communicate the school’s process for facilitating students’ disability disclosures and requests for reasonable accommodations, (3) avoid language that might prompt persons with disabilities to self-select out of the school’s class, and (4) be posted online.46 It is also important that consideration of disabilities includes psychological, learning, or chronic health disabilities, as these are represented in a majority of documented disabilities in medical school.18
Rising to a Legal Minimum is Not Inclusion
Medical schools that are only willing to do the legal bare minimum8,50 to reasonably accommodate students with disabilities fail to embrace the spirit of the law, the goals of inclusion, and disability itself as an important element of diversity. A compliance-based approach to disability inclusion is ethically insufficient to promote students’ comfort with disclosure and nourish the kind of productive engagement students with disabilities deserve in response to their requests for reasonable accommodations.51 Medical schools fully expressing a good faith commitment to disability as diversity—over and above the bare minimum—are actively creating student services infrastructure and the faculty education and training needed to support students’ disability disclosures and accommodation requests.15 Schools’ policies and practices should also be reviewed and amended when needed to align with best practices. Medical schools looking to promote holistic review of applicants can help innovate medical education by hosting workshops on holistic admissions; in fact, those that have done so have demonstrated sustained growth in diversity among their students.52
Evaluating applicants with disabilities. Medical schools’ admissions policies and practices must be procedurally just before they can effectively promote equity and inclusion. Anti-ableist training is a must for all admissions committee members, just as holistic review31 of applicants is a must for reframing disability as value added to medical schools looking for students with resilience and grit.53 Outreach efforts to identify, recruit, and retain students from diverse backgrounds should seek out students who have cultivated these character traits by navigating life with a disability in an ableist world.51
Accommodations’ reasonableness. Whether an accommodation would fundamentally alter a program or pose undue administrative or financial burdens on a school are not admissions decisions51 and should be adjudicated by an informed disability resources professional in partnership with the program.15,54 Moreover, accommodation decisions are ancillary to the academic and personal characteristics evaluated by admissions committees; evaluation of the reasonableness of a person’s request for accommodations, therefore, should occur between an offer of admission and the student’s matriculation.46 Indeed, disability equity and inclusion require schools to make clear distinctions between their admissions and student services operations.
Inclusion of individuals with disabilities in medicine is a highly influential way to promote equity.6,7,8,9,10,11,12,55 Increasing representation among students, trainees, and physicians with disabilities so as to be more reflective of the people they serve can also mitigate harmful effects of clinician bias on colleagues, patients, and their loved ones during clinical encounters.56,57,58,59,60,61 There is value in the disabled person’s dual lived experience as a patient and as a professional that can motivate clinicians and colleagues to be more informed practitioners, the medical profession to be more just, and society to resolve health care disparities.
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