More than 90% of medical students with disabilities have conditions that aren't obvious: learning disabilities, ADHD, psychological disabilities, and chronic health conditions. Here's why we need to make curricula — and peers and instructors — much more welcoming to learners with hidden disabilities.
Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
Justine* grew up in a small town and with few advantages, so when she was accepted into a top medical school — on a full scholarship, no less — she was completely thrilled. Yet as her first day approached, she became increasingly anxious about a crucial decision that lay ahead.
Often, when people hear the word “disability,” they think of someone who has difficulty walking, hearing, seeing, or speaking. But the reality among the 2.7% of medical students with disabilities is quite different. In fact, the vast majority of medical students with disabilities — about 92% — have nonapparent conditions such as ADHD, psychological disabilities, learning disabilities, and chronic health conditions. And though students like Justine are not uncommon in medical school, the unfortunate truth is that they are not always well understood or welcomed.
If we are going to achieve true equity in medical school — and attract a wide pool of talented future physicians — we must change the attitudes and cultures that prevent students with nonapparent disabilities from thriving. To be fully inclusive, medical schools need to acknowledge and shed any biases against students with these disabilities and implement policies and procedures that fully embrace and support them.
Students with nonapparent disabilities notice that institutions sometimes warmly welcome students with physical disabilities and even feature those students in campaigns about diversity. Perhaps that’s because people more easily accept the validity of a disability they can see, but have a hard time imagining the barriers that students with nonapparent disabilities face. Yet a student with an autoimmune disorder who gets to sit while others stand in surgery, for example, may have gotten up an hour early to take a hot shower, do stretches, and take medication, but none of this is visible to those around him.
Often, when people hear the word “disability,” they think of someone who has difficulty walking, hearing, seeing, or speaking. But the reality … is quite different.
Students like Justine often live with the fear that faculty will assume that they are trying to “game the system” for better grades and other advantages — and I’ve personally heard faculty members question accommodations’ fairness to other students. Yet students with disabilities are simply using accommodations such as extra time on an exam to level the playing field.
Sometimes, peers can be insensitive. They may make comments like, “I have trouble concentrating sometimes too, so I’d love more time on tests.” Offensive comments frequently come at the expense of students with psychological disabilities, who might hear things like, “We are all stressed and anxious, so maybe you just can’t handle medical school.”
Such attitudes discourage students with nonapparent disabilities from requesting the accommodations they need. What’s more, these attitudes also may lead students to begin doubting themselves, their need for accommodation, and even whether they should pursue a medical career. That’s a shame, because these students so often make highly motivated, compassionate physicians.
Institutions need to celebrate and support students regardless of disability type, and several proven steps can help them achieve this critical goal. In 2018, my colleague Neera Jain, MS, CRC, and I co-authored an AAMC report on the state of disability in medical education. It includes an easy-to-navigate appendix with suggestions that can be used as a roadmap for improving inclusion, and it’s available for free.
If we are going to achieve true equity in medical school — and attract a wide pool of talented future physicians — we must change the attitudes and cultures that prevent students with nonapparent disabilities from thriving.
One effective way to improve inclusion is to ensure that curricula and assessments work for people with many different learning styles, an approach called universal design of instruction. Presenting material in multiple formats — video, hands-on learning, small groups, and lectures, just to name a few — not only helps students with learning disabilities but numerous other students who also benefit from varied approaches.
In addition, when creating curricula and assessments, schools should build in extra time for students with disabilities who may need it for exams. Or schools can take an approach that removes this need entirely: Yale School of Medicine, for example, has decided that all exams in preclerkship years are untimed and given over a several-day window, choosing to focus on content knowledge rather than time.
Another vital way to deepen inclusion is to ensure that disability-related policies and processes are clear and supportive. Information on websites and in personal communications should indicate a school’s commitment to embracing all types of disability as part of diversity. Also crucial is letting students know how to disclose a disability and request accommodations — and encouraging them to do so. Several schools are working to publicize their commitment to disability and intentionally include language that encourages students to connect with staff to ensure equal access.
Several schools are working to publicize their commitment to disability and intentionally include language that encourages students to connect with staff to ensure equal access.
Finally, appropriate and meaningful accommodations are essential to equal access. Sometimes, schools accommodate students by waiving some requirements in a clerkship when they know that a student with a disability doesn’t intend to specialize in that field. However, instead of waiving a requirement, schools should aspire to create an equally meaningful experience via creative accommodations or modifications. For example, an anesthesia attending might make a rotation meaningful for a blind student by reverting to old-school methods of monitoring a patient’s vital signs — such as listening to lungs — in lieu of looking at machines. Of course, clinical education often requires highly specialized accommodations, and schools that want to adopt appropriate and reasonable accommodations can learn more from organizations like the Coalition for Disability Access in Health Science.
As for Justine, she landed at a supportive institution. During orientation, for example, the dean of students announced that students with disabilities — regardless of type — are encouraged to meet confidentially with the access specialist. When she met with the specialist, she was relieved to learn that assistive technology and extra time are built into the curriculum and are part of the normative culture of the institution. Justine was fully able to engage in medical school and display her many capabilities. She even began using some new assistive devices that will help her in residency and practice. Justine ultimately matched into her first-choice residency. Thanks to a robust and informed system at her school, her decision to engage with it, and much hard work, today Justine is a successful surgical fellow.
* Not her real name