By: Jacqueline A. Wynter, OTD, OTR/L
How do medical school curricula address disability issues?
Are there model programs that could be replicated?
Impact of Disability on Health and Healthcare Provider Bias
People with disabilities often have difficulties accessing healthcare services, resulting in unmet healthcare needs and poorer health outcomes compared with people without disabilities (WHO, 2015). Obstacles to accessing health services for people with disabilities include (a) physical barriers related to the architectural design of health facilities; (b) health care providers’ skill level; (c) and unconscious biases about the health and quality of life of people with disabilities (WHO, 2015). Lack of knowledge about the Americans with Disabilities Act (ADA) and healthcare provider bias both contribute to poorer healthcare outcomes for people with disabilities. For example, negative attitudes of health care providers can result in inadequate physical examinations, diagnostic testing, and the poor provision of preventive services (Symons, Morley, McGuigan, Aki, 2014).
Healthcare providers’ lack of knowledge about the ADA was evident in a study conducted by Georgia State University. In the study, 57 nurses were surveyed to gauge healthcare providers’ knowledge of the ADA and practices related to providing healthcare aligned with the ADA. The study found that over 80% of participants reported being “somewhat’ or “not very familiar” with ADA compliance. Participants also had limited knowledge of their legal responsibilities under the ADA. Eighty-six percent of participants had never received formal training on ADA compliance in health settings. More than half of the participants indicated that a lack of time and/or lack of formal education or training was a barrier to providing care for patients with disabilities. Some participants noted they did not hear colleagues discuss the ADA or patients with disabilities and when asked about their knowledge and the provision of reasonable accommodations, including where or how to find accommodations or even how to provide accommodations if patients needed them. Nearly all the participants noted they would ask their charge nurse first. When asked how to develop a training that would be engaging to them, the nurses felt that a hybrid or online format would work best and recommended continuing education hours as a way to gain such training (Vinoski Thomas, E., Smith, S. E., & Awel, S. (accepted) (Thomas, Smith, Awel, 2023).
Another study involving physicians indicated they had little or no training on the ADA. Some physicians mentioned their bias toward the ADA, stating they felt it harmed their patients due to the fear of lawsuits it created among physicians. Many physicians implied that providing accommodations for people with disabilities was burdensome. Some physicians even stated that they tried to deny care for people with disabilities or prematurely discharge them. The study demonstrates the need to address barriers to healthcare for people with disabilities. (Lagu et al., 2022). One key way to address this barrier is to shift how disability is viewed and taught.
Medical Model vs Social Model of Disability
Ableist thinking is deeply embedded into the culture and can lead to prejudices and bias (Borowsky, Morris, Garg 2021). Understanding ableism is essential to the understanding of disability (Borowsky, Morris, Garg 2021). Ableism treats disabilities as deficits to be overcome and views physical capability, neurotypicality and able-bodiedness as the norm (Borowsky, Morris, Garg 2021). Ableism is tied to the medical model of thinking which views disability through a medical lens (Rajkumar, 2022). The medical model’s perception of disability is that disability reduces the quality of life and aims to fix and diminish disability through medical interventions (Rajkumar, 2022). The medical model does not have a holistic view of a person and does not take into account the individual’s environment or social context (Borowsky, Morris, Garg 2021).
The social model of disability, on the other hand, views disability as the result of the interaction between people living with disabilities and an environment full of attitudinal, physical, communication, and social barriers (Rajkuman, 2022). It emphasizes a need for social change to accommodate people with disabilities (Rajkuman, 2022). The social model of disabilities does not view the person with a disability as someone who is broken and needs to be fixed. In order to move toward more holistic medical care of people with disabilities, it is important to begin with education. It is essential to expose medical students to the issues and healthcare disparities faced by people with disabilities while they are still undergoing their educational training. Health worker training on disability is key to achieving high standards of health for people with disabilities (Rotenberg et al., 2022). Medical students must develop a firm grasp on the social and structural determinants of health (Borowsky , Morris, Garg, 2021). A shift away from the medical model, toward the social model of disability may help medical students and future physicians better serve their patients with disabilities.
Medical School Training
Professional and advocacy organizations including the American Association of Medical Colleges have identified the need for medical schools to provide disability training to their students (Loerger et al., 2019). Despite this identification for the need to provide training, there is not yet a consensus on how medical schools are to provide such training (Loerger et al., 2019). However, training should incorporate meaningful, evidence-based designs and methods (Loerger, et al., 2019). This training should (a) aim to teach medical students the knowledge and skills they will need to treat their patients with disabilities, (b) use established objective measures of desired outcomes, like a pretest or control group, to provide evidence of a change or differential impact, and (c) should include longitudinal follow-up evaluations (Loerger et al., 2019). Several methods have been recommended to teach medical students about disability. They include teaching them empathy, having people with disabilities lecture, using case studies, providing standard patient education, using a flipped classroom, using modules, and designing a multipronged approach.
Teaching Empathy
Empathy is influenced by sex, age, personal experience, and psychological well-being (Cecchetti et al., 2021). Empathy is important for doctors, yet empathy levels of medical students decline over time (Cecchetti et al., 2021). This could be an adaptive coping mechanism medical students develop to protect themselves and avoid burnout (Cecchetti et al., 2021). Medical students’ training should be designed to teach them to be compassionate and empathetic while providing quality care to their patients with disabilities (Cecchetti et al., 2021). Effective disability education interventions should be designed to improve negative attitudes toward people with disabilities and increase empathy levels.
A fixed-quasi-experimental longitudinal design study about empathy conducted at the School of Medicine, University College of Dublin during the 2015-2016 school year showed empathy of medical students one year after the completion of a module on disability decreased at the one-year follow-up. The study showed attitudes were not stable constructs and were likely to change over time, which could have ramifications for the design of educational interventions focused on addressing the negative attitudes of students toward disability (Cecchetti et al., 2021). The evidence suggested that including disability-related content in medical school training may not be enough to address lasting attitude changes or increase empathy of medical students toward people with disabilities. Methods are needed to identify how learning can be translated into long-term and sustainable change (Cecchetti et al., 2021).
People with Disabilities as Lecturers
Some educational programs have invited people with disabilities to speak or lecture to medical students about their experiences with the healthcare system (Rotenberg et al., 2022). This has included inviting people with disabilities to participate in simulated patient programs. Cardiff University hired a self-advocacy theater group to run a simulation and icebreaker activity. Having people with disabilities lecture can add a non-clinical angle to disability training and allow students to explore disability outside of the health care and educational setting (Rotenberg et al., 2022). Studies that have measured participants’ attitudes and comfort levels before and after a person with a disability was the teacher/lecturer have demonstrated that participants felt the non-clinical interaction improved their comfort and attitudes toward people with disabilities (Rotenberg et al., 2022).
Case Studies
Case studies are frequently used in health education to teach clinicians how to best address the needs of their patients. They include details about the patient and clinical observations used to teach students (Rotenberg et al., 2022). Case studies are also very commonly used in professional development for healthcare workers. They can be beneficial in helping medical students identify areas that they may have otherwise overlooked, however, they may not get the full perspective of the patient with the disability.
Standard Patient Encounters
Standard patient encounters are another frequently used method to teach clinical skills to medical students. Standard patient encounters can provide agency for people with disabilities, allowing them to speak for themselves and demonstrate their quality of life (Keller, 2022). This method can provide opportunities to meet the goals of medical education in developing students’ clinical skills and improving and evaluating students’ understanding of and attitudes toward people with disabilities. Medical schools that want to incorporate disability into their curriculum could benefit from using standardized patient encounters (Keller, 2022).
Flipped Classroom
A flipped classroom is a technique where students read and study materials before discussing them and engaging in related activities with their fellow classmates (Keller, 2022). This method allows students to present information based on background information which can result in more meaningful classroom engagement and discussion (Keller, 2022). Qualitative analyses have shown that students recognize the value of learning the information in order to support their patients and their families (Keller, 2022). However, there is little research on the use of flipped classrooms’ effects on the attitudes of medical students toward people with disabilities (Keller, 2022).
Modules
Modules are another frequently used method employed to educate medical students about people with disabilities. Modules can vary in length and detail, ranging from the very general to the very detailed. However, modules have been shown to be beneficial in teaching medical students about people with disabilities and how to best treat them in a clinical setting (Keller, 2022). Modules may include case presentations, lecturers from disability advocates and visits to a rehabilitation hospital, and guest lecturers from other healthcare providers including allied health professionals such as occupational, physical, and speech therapists (Keller, 2022). Modules may also include clinical placements that expose medical students to the lived experiences of people with disabilities (Keller, 2022). Rehabilitation programs and professionals and physical medicine rotations can provide medical students with excellent hands-on experiences working with people with disabilities as this is a core skill needed to work in these departments. Allied health rehabilitation programs have already established ways to provide meaningful interactions with people with disabilities, which can result in medical students improving their comfort and skill in interacting with people with disabilities (Keller, 2022).
Multipronged Approach
A multipronged approach can help students with different learning styles. A study on disability training for healthcare workers, including doctors, medical students or residents, nurses, nursing students, and occupational and physical therapists, that reviewed 78 articles from 19 countries, showed that approximately 75% of the papers reviewed used a combination of methods to train participants. The State University of New York medical colleges demonstrated the importance of integrating disability across health worker curricula as all participants significantly improved their knowledge, attitudes and core competencies (Rotenberg et al., 2022). The University of South Florida had a 12-week clinical clerkship program that included lectures, classroom simulations, case studies and people with disabilities as teachers, and a placement in a community clinic that served people with disabilities. This program significantly improved the knowledge, comfort, and attitudes of health care students (Rotenberg et al., 2022). A multipronged approach can allow students to improve their comfort level and develop their clinical skills working with people with disability across different settings and scenarios.
Medical Schools and Disability Education
Cardiff University, the School of Medicine, University College of Dublin, the State University of New York medical college, and the University of South Florida have all been cited for their approaches to teaching their medical students about people with disabilities. Other programs noted for their training of their medical students include The Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo and The University of California San Francisco (UCSF).
The Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo has developed a longitudinal curriculum that includes disability education throughout all 4 years of their students’ education (Englander et al., 2016). First-year students attend lectures about the history of disability, participate in small group meetings with patients with disabilities and their families, and have the opportunity to participate in a Family Medicine summer research internship that focuses on providing healthcare to patients with disabilities. Second-year students attend lectures and participate in structured clinical examinations with patients with disabilities. Third-year students learn about caring for patients with disabilities and the social context of providing care through educational and clinical training. Fourth-year students can choose to participate in a 4-week elective in primary care for patients with disabilities education (Englander, et al., 2016).
For their first-year medical students, UCSF School of Medicine developed both a 2-hour training session about disability and ableism in medicine curriculum and a health and the individual course (Borowsky, Morris, Garg 2021). Discussions were student led and sessions included brainstorming to address healthcare barriers and biases. The sessions were evaluated through pre and post surveys and a 1-year follow-up. The feedback collected indicated that medical students found the sessions relevant and meaningful and rated the sessions highly, a 4.6 out of 5, (Borowsky, Morris, Garg 2021). Data analysis indicated students felt the sessions improved their understanding of ableism and improved their confidence in addressing barriers to caring for people with disabilities, (Borowsky, Morris, Garg 2021). In the one-year follow-up, students felt that the sessions had impacted the way they thought of caring for patients with disabilities. The sessions introduced medical students to ableism and the social model of disability and stimulated student interest (Borowsky, Morris, Garg 2021).
Conclusion
People with disabilities have poorer health outcomes in part due to the biases of the healthcare workers who treat them. To address this disparity in health care, health care providers, including physicians, must change the way they view patients with disabilities and move from a medical model to a social model of disability. The social model should be integrated into the medical school curriculum to change the way medical students are taught to treat and interact with people who have disabilities.
Medical school courses of study should adopt a multipronged approach to educate their students about how to effectively and respectfully treat with people with disabilities. This should include training students on disability and empathy, the use of modules, flipped classrooms, case studies, and having people with disabilities as lecturers to share their lived experiences. Students should also be provided with opportunities to engage with people with disabilities in both clinical and nonclinical environments. Medical schools should engage in longitudinal studies with their students to assess their views over time and make changes to their curriculum as needed.
Additionally, after graduation, continuing education for healthcare providers, including nurses and physicians, should keep practitioners abreast of best practices needed to serve their patients with disabilities and ensure they are aware of laws and regulations that provide protections to individuals with disabilities. Modifications in the way medical students are trained and view people with disabilities can result in sustained changes that can address health disparities and improve outcomes for people with disabilities.
References
Borowsky, H., Morinis, L., & Garg, M. (2021). Disability and Ableism in Medicine: A Curriculum for Medical Students. MedEdPORTAL, 11073. https://doi.org/10.15766/mep_2374-8265.11073
Cecchetti, M., Last, J., Lynch, J., & Linehan, C. (2021). Evaluating the longitudinal impact of a disability education intervention on medical students’ attitudes towards persons with a disability. Disability and Health Journal, 14(3), 101092. https://doi.org/10.1016/j.dhjo.2021.101092
Englander, R., Flynn, T., Call, S., Carraccio, C., Cleary, L., Fulton, T. B., Garrity, M. J., Lieberman, S. A., Lindeman, B., Lypson, M. L., Minter, R. M., Rosenfield, J., Thomas, J., Wilson, M. C., & Aschenbrener, C. A. (2016). Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency. Academic Medicine, 91(10), 1352–1358. https://doi.org/10.1097/ACM.0000000000001204
Keller, M. A. (2022). Doctors and Disability: Improving Inclusion in Medical Education. HCA Healthcare Journal of Medicine, 3(3). https://doi.org/10.36518/2689-0216.1393
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Rajkumar, S. (2022, August 8). How to talk about disability sensitively and avoid ableist tropes. NPR. https://www.npr.org/2022/08/08/1115682836/how-to-talk-about-disability-sensitively-and-avoid-ableist-tropes
Rotenberg, S., Rodríguez Gatta, D., Wahedi, A., Loo, R., McFadden, E., & Ryan, S. (2022). Disability training for health workers: A global evidence synthesis. Disability and Health Journal, 15(2), 101260. https://doi.org/10.1016/j.dhjo.2021.101260
Symons, A. B., Morley, C. P., McGuigan, D., & Akl, E. A. (2014). A curriculum on care for people with disabilities: Effects on medical student self-reported attitudes and comfort level. Disability and Health Journal, 7(1), 88–95. https://doi.org/https://doi.org/10.1016/j.dhjo.2013.08.006
Vinoski Thomas, E., Smith, S. E., & Awel, S. (accepted). Nurses’ and nursing students’ knowledge of disability-competent care: Needs assessment to inform training development. Poster to be presented at the American Public Health Association conference, November 2023, Atlanta, GA)
World Health Organization. (2015). WHO global disability action plan 2014-2021: better health for all people with disability. World Health Organization. https://apps.who.int/iris/handle/10665/199544
Disclaimer
These materials do not constitute legal advice and should not be relied upon in any individual case. Please consult an attorney licensed in your state for legal advice and/or representation. These materials were prepared in partnership with the Southeast ADA Center to highlight developments relevant to the impact on health care access and the Americans with Disabilities Act (ADA). These materials are based on information in effect at the time of publication. Federal and state disability rights law can change at any time. In addition, state and local laws and regulations may provide different or additional protections. Materials are intended solely as informal guidance, and are neither a determination of your legal rights nor responsibilities under the ADA or other federal, state, and local laws, nor binding on any agency with enforcement responsibility under the ADA. The accuracy of any information contained herein is not warranted. Any links to external websites are provided as a courtesy and are not intended to nor do they constitute an endorsement of the linked materials.
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