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A More Level Playing Field for Students with Disabilities in the Medical Sciences

Timothy Cordes graduated as valedictorian of his class at the University of Notre Dame. He was admitted to the University of Wisconsin (UW) where he recently earned an M.D. and a Ph.D. in biomolecular chemistry. He is currently a resident physician in the psychiatry department while fulfilling his role as a husband and father. Tim is blind. That this uncommon constellation of accomplishments can occur is notable. Ten or twenty years ago, it would have been impossible.

Twenty years ago, while serving as a faculty pre-med advisor at Harvard College, I was assigned a candidate for medical school admission: a graduate of the Bronx High School of Science, an outstanding student, a basketball player, personable, and impressive in every way. He was a “dream” candidate with one exception: He had been born deaf. Our efforts to gain his admission to medical school were a nightmare. Despite personal communications to medical school deans and admission directors, as well as letters from his professors attesting to his abilities, all doors were closed. He entered a Ph.D. program in pathology at the University of Pennsylvania and, following postdoctoral training at the National Institutes of Health (NIH), now does exciting research in the field of congenital deafness.
    
Recently, I was reminded of this experience when I sat down for a mentoring session with a second year medical student here in Madison. “I’ll need to see your lips,” the student cautioned me as we began our conversation, “I’m congenitally deaf.”


Why has the situation regarding the admission of students with
disabilities to medical schools altered – and how completely has it
altered? What was the rationale for excluding blind or deaf students,
students with dyslexia, or students in a wheelchair, and how justified
was it? Can students with disabilities be successful in medical careers?
And what are the costs and benefits to society? Let’s first  consider
the Americans with Disabilities Act (ADA) of 1990.

The Americans
with Disabilities Act (ADA) of 1990 forbids denying access to education
on the basis of disability alone. This law requires the clear
definitions of “basic qualifications” required of all applicants,
“essential elements” of the curriculum, and clarification of whether
admission would alter the “fundamental nature” of the learning
experience or impose “undue burden.” In 1993, the Association of
American Medical Colleges (AAMC) responded to the ADA with guidelines
for medical schools entitled “The ADA and the Disabled Student in
Medical School,” which stated that “all students must possess the 
intellectual, physical and emotional capabilities necessary to undertake
the required curriculum in a reasonable independent manner, without
having to rely on intermediaries, and that all students must be able to
achieve the levels of competence required by the faculty.”
    
From
my standpoint as a pre-med adviser, it was clear that following
enactment of the ADA, medical schools had two major concerns regarding
the admission of  students with disabilities. One was their ability to
function adequately as physicians. The second was the need for
additional resources and personnel during their training. Even then, I
believed that the standard set by AAMC was unnecessarily high, and,
hence, presented an unnecessary burden to students with disabilities.

During
my medical school years in the 1960s, at the University of
Pennsylvania, the chief of endocrine services was Dr. Edward Rose. An
outstanding clinician and teacher, Dr. Rose had become blind in adult
life. With the assistance of his wife, a distinguished pediatrician,
Rose effectively taught hundreds of medical students and supervised and
participated in the treatment of patients in the endocrine clinic.
Another faculty member in the public health department had been a
“rubella baby” with profound hearing loss since childhood, but he also
was outstanding in his field.

Examples such as these impressed
upon me and my class members the unfairness of the existing admission
criteria and prejudices that prevailed then (and until quite recently)
for applicants with disabilities to medical school. The medical school
admission criteria reflected the widespread stereotypes and negative
attitude toward people with disabilities in general. Admissions
decisions were made by small committees of faculty who tended to choose
students having traits similar to those who had been successful in the
past; these committees ignored the potential that vision-, hearing-, and
mobility-impaired people had for a medical career.
 
Why have
attitudes changed? It has became clear that physicians who acquired 
physical disabilities after medical school, like Dr. Rose at Penn, can
continue to be effective in many forms of medical practice. The ADA was a
very big factor, changing attitudes toward people with disabilities in
other fields and demonstrating that their training does not impose
“undue burden.” Medicine took the example, eventually coming to believe,
as I do, that we have a moral obligation to consider for admission all
students who have the intelligence, character, and ability to become
highly qualified physicians.
    
Michael J. Reichgott at Albert Einstein College of Medicine writes,
“With respect to clinical training, it is important to consider whether
personal, hands-on experience is required for adequate learning to
occur. Because most physicians limit the scopes of their practices and
do not perform all procedures, . . . and because technologic advances
allow for the substitution of imaging and diagnostic testing for the
more conventional approach to the physical examination, the requirement
for hands-on capability becomes less compelling.” (Reichgott, M. J.
“Without handicap”: issues of medical schools and physically disabled
students. Academic Medicine: Journal of the Association of American
Medical Colleges. 1996; 71: (12): 1275-6.)
    
This is not to
imply that every pre-medical student with physical disabilities should
be admitted to medical school. And for those who are admitted, it must
be recognized that most will require additional assistance, support, and
career advice to succeed.

When I was at Harvard, I was a faculty
adviser to a pre-medical student who had severe dyslexia. He could not
learn from written sources, so he was provided with a reader. He
excelled as a student. Upon applying to medical schools, he elected not
to mention his disability, and by law it could not be mentioned in the
material supplied by Harvard to the schools he applied to. He was
accepted at an outstanding medical school, which initially expressed
displeasure when they learned of the disability and the need for a
reader. Yet, this student graduated near the top of his medical school
class and has had an outstanding career as a physician.

Other
examples of medical students with disabilities succeeding both in school
and in their careers are numerous and can be found in the literature
(e.g., Maughan, D. Disabled as medical student, enabled as doctor. BMJ:
British Medical Journal. 2005; 330: (7505): 1455.) and the press (e.g., Linda Villarosa, Barriers Toppling for Disabled Medical Students, NY Times, November 25, 2003.).
    
A more enlightened policy toward applicants with disabilities is prevalent today. The stated policy of the University of Maryland Medical Scientist Training Program (MSTP) is representative:
 

The
MSTP values diversity, inclusion and welcomes students with
disabilities.  We encourage people with disabilities to apply and make
every effort to ensure that all qualified applicants can take full
advantage of the programs available here on campus. The MSTP gives full
consideration to all applicants for admission . . . We provide
reasonable accommodations as needed to those with disabilities and
determinations are made on a case-by-case basis.

The
benefits of such a policy to society are many. The gifted, disabled
physician can have a rewarding career and benefit medicine and science.
Patients and society benefit from these efforts. Meanwhile, classmates
of the disabled student gain empathy and learn a lesson in courage.

This
leveling of the playing field has come slowly. Tribute should be paid
to the efforts of those in medical education who played a role in
bringing it about. So, I’ll end this post with an anecdote communicated
to me by Dr. Alan Morse, the CEO of the Jewish Guild for the Blind:

In
the early 1980’s, Ephraim Freidman and I were having a discussion about
medical school curriculum. At that time, Eph was the dean of Albert
Einstein College of Medicine. Because Eph was an ophthalmologist, I
thought that he was in an ideal position to improve the curriculum and
add more information about eye disorders and visual impairment. That
seemed important to me since so many of the individuals we were seeing
at The Guild were diagnosed too late to save much of their vision, most
often due to lack of appropriate referral and follow-up. After
concluding that there was scant space in the curriculum to add anything,
Eph then asked me a question. Knowing of my interest in expanding
opportunities for individuals with disabilities, he asked whether,
presented with a blind medical school applicant, with obviously
excellent grades, MCAT scores and everything else, would I admit him? I
reasoned that in a perfect world, sure, but with the limited resources,
the small number of positions, the intense competition, etc., it didn’t
seem right to waste one position since there would be severe practice
limitations for this individual should he ever graduate and complete his
training. We talked about how visual medicine was, from clinical
observation of skin color, body language, tremor — even in specialties
like psychiatry — to the laboratory, to virtually everything in
medicine. He agreed, but added, “we admitted him.” He reasoned that
there would never be a better opportunity to educate 130+ future
physicians about the competencies and capabilities of someone who is
blind. I’m sure that Eph’s bold decision and object lesson in
non-discrimination — more than 10 years before the passage of the
Americans with Disabilities Act — was not lost on this individual’s
classmates.

It is this type of thinking that made
possible the promising careers of Timothy Cordes and my deaf second-year
medical student mentee.

For further information, please visit the Society of Disabled Healthcare Professionals (SDHP) at http://www.disabledhealthprofessionals.org/.
They provide resources and support for physicians, nurses, pharmacists,
and other health care professionals with disabilities. Membership is
free and open to healthcare professionals, friends, family members, and
others who wish to support the Society of Disabled Healthcare
Professionals.

Also, the American Association for the Advancement
of Science (AAAS) offers internship opportunities for students with
apparent and non-apparent disabilities in science, engineering,
mathematics, computer science, and some fields of business. For more
information, please visit http://ehrweb.aaas.org/entrypoint/.