The Prevalence of Disability Health Training and Residents With Disabilities in Emergency Medicine Residency Programs

"Pain is not typically taken into consideration due to him being nonverbal"- emergency department experiences among persons with disabilities: a mixed methods study in Kingston, Ontario

Background

Persons with disabilities (PWD) are more likely to visit the emergency department (ED) and often have complex health needs when accessing care in the ED. Yet there is limited understanding of ED care experiences among PWD, especially in a Canadian context. The aim of this study was to examine the ED care experiences of PWD in contrast to a comparison group in Kingston, Ontario to better understand their health care needs.

Methods

A mixed-methods study with a community-based participatory approach examining participants' past ED care experiences (within 24 months) was conducted in Kingston, ON. Quantitative data from those with disabilities and those from the comparison group were compared using chi squared tests to identify differences between groups. An inductive and deductive thematic analysis approach was used to identify themes in the shared qualitative data. Convergence of findings across quantitative and qualitative data was undertaken.

Results

A total of 175 participants identified as having a disability. In contrast with the comparison group (N = 949), PWD were more likely to report being given too little attention to their needs (p < 0.001), that it was more important to be treated with kindness/respect than to receive the best possible medical care (p < 0.001), to report feelings of disrespect and/or judgement (p < 0.001), and that better understanding of personal identity/situation/culture and better communication would improve ED care. Qualitative analysis highlighted the following themes: poor communication between PWD and health care providers (HCP), compassionate medical care received, perceived HCP negative attitudes/beliefs related to having a disability and substance misuse, and perceived HCP lack of knowledge/skill to treat the unique health needs of PWD.

Conclusion

Findings highlight the need to improve ED care for PWD. Future quality improvement initiatives should focus on incorporating a deeper understanding of disability into medical education and emergency medicine (EM) residency education, designing curricula that emphasize cultural humility, and implementing community-based placements providing opportunities for health professionals to work with and learn from PWD.

Internal Medicine Program Directors' Perceptions About Accommodating Residents with Disabilities: A Qualitative Study

BACKGROUND

While 26% of US adults are disabled, only 3.1 to 9.3% of practicing physicians report having a disability. Ableism within medical training and practice diminishes physician diversity and wellbeing and contributes to healthcare disparities.

OBJECTIVE

Explore physician barriers to disability equity and inclusion by examining internal medicine (IM) program directors' (PD) perspectives about recruiting and accommodating residents with disabilities (RWD).

DESIGN

Qualitative study involving semi-structured virtual interviews (conducted December 2022-September 2023; analyzed through December 2023).

PARTICIPANTS

PDs were recruited via email. Purposive sampling captured program diversity in size, location, and affiliations. Convenience sampling ensured PD diversity by gender, race/ethnicity, and age.

APPROACH

Coders analyzed thematic and discursive content of interview transcripts to characterize PD perspectives about RWDs and accommodations.

KEY RESULTS

Of the 15 programs represented, 4 had ≤ 49 and 8 had ≥ 100 total residents. Three were community-based; the rest had academic affiliations. On average, PDs had 17 (SD 8.2) years in practice. Most (11/15) identified as White race; 8/15 as female; and none as disabled. PDs characterized disability as a source of grit and empathy but also as an intrinsic deficit. They worried RWDs could have unpredictable absences and clinical incompetencies. Perceived accommodation challenges included inexperience, workload distribution, information asymmetry about accommodation needs or options, barriers to disclosure (e.g., discrimination concerns), and insufficient accommodation advertising. Perceived facilitators included advanced planning; clear, publicized processes; and access to expertise (e.g., occupational health, ombudsmen).

CONCLUSIONS

PDs held contradictory views of RWDs. PD insights revealed opportunities to alleviate PD-RWD information asymmetry in recruitment/accommodation processes, which could help align needs and improve representation and inclusion.

Developing an Inclusive Training Environment: Accommodations in Physical Medicine and Rehabilitation Residency Training for Residents With a Disability

ABSTRACT

This study examines the challenges and accommodations for medical residents with disabilities within physical medicine and rehabilitation training programs. Medical residency presents unique stressors and responsibilities, with the potential for added complexities for residents with disabilities. Few data exist regarding the prevalence and experiences of people with disabilities as medical trainees and the limited studies available highlight an underrepresentation of individuals with disability in medical training and practice. Through cross-sectional surveys administered to physical medicine and rehabilitation residents, this research assesses disability prevalence, characterizations, barriers to training, and accommodations provided. Of 140 respondents, 9.3% identified as having disabilities, with varying prevalence among genders and disability types. Results revealed distinct challenges for residents with mobility and nonmobility disabilities, spanning learning environments, standardized testing, procedural skills, and accessibility. Self-provided accommodations exceeded program-provided ones, indicating room for improvement in program support. These findings underscore the need for proactive dialog between residents and leadership to address barriers, enhance accommodations, and create an inclusive training environment. The study's insights emphasize the importance of advocating for equal opportunities and cultivating supportive conditions to enable individuals with disabilities to thrive in medical residency programs, ultimately contributing to more diverse and inclusive medical communities.

Come Roll with Me: An Interprofessional Experience to Promote Disability Awareness

Problem: One in four American adults have a disability, which makes people with disabilities the largest minority group in the United States (U.S.). Chronic diseases are prevalent within this population, which faces myriad barriers that limit access to healthcare and create significant health care disparities. Yet, disability awareness programs are limited in U.S. medical schools and graduates report a sense of unpreparedness to care for this population. Intervention: Come Roll with Me (CRWM) was implemented as an interprofessional, preclinical experience to provide medical and Doctor of Physical Therapy (DPT) students an opportunity to engage with wheelchair users and one another. Students rotated through four stations with a licensed physical therapist and wheelchair user facilitator. Stations included (1) manual wheelchair self-propulsion, (2) accessible parking, (3) transfers, and (4) open dialog on barriers to healthcare led by the wheelchair user. Context: This study sought to assess the impact of CRWM on students' understanding of the barriers and health disparities faced by individuals with disabilities. Assessment was conducted using course evaluations, thematic analysis of student reflection essays and a focus group with the wheelchair user facilitators to determine if CRWM met pre-implementation program goals and objectives, including the Interprofessional Educational Collaborative (IPEC) core competencies. Impact: Student reflections from both disciplines indicated that learners were able to identify a variety of barriers faced by people with disabilities and prioritize methods to mitigate these factors. Approximately 91% of medical students agreed or strongly agreed that CRWM was effective in their learning on course evaluations. Wheelchair user facilitators noted three important outcomes of CRWM: educating, teaming, and impact on students. Lesson Learned: Come Roll with Me is a robust educational activity, as evidenced by the program meeting all goals and objectives as well as (IPEC) core competencies. It provides students a unique opportunity to learn about disability from another profession and wheelchair users. People with disabilities and DPT students are a unique and underutilized pool of educators in undergraduate medical education.

Disability Inclusion in Psychiatry: Strategies to Improve and Increase Diversity Within the Psychiatrist Workforce

The number of psychiatrists with disabilities is not well studied but the inclusion of mental health providers with disabilities is integral for the betterment of psychiatry and patient care.

Emergency department patient-centred care perspectives from deaf and hard-of-hearing patients

BACKGROUND

Deaf and hard-of-hearing (DHH) patients are a priority population for emergency medicine health services research. DHH patients are at higher risk than non-DHH patients of using the emergency department (ED), have longer lengths of stay in the ED and report poor patient-provider communication. This qualitative study aimed to describe ED care-seeking and patient-centred care perspectives among DHH patients.

METHODS

This qualitative study is the second phase of a mixed-methods study. The goal of this study was to further explain quantitative findings related to ED outcomes among DHH and non-DHH patients. We conducted semistructured interviews with 4 DHH American Sign Language (ASL)-users and 6 DHH English speakers from North Central Florida. Interviews were transcribed and analysed using a descriptive qualitative approach.

RESULTS

Two themes were developed: (1) DHH patients engage in a complex decision-making process to determine ED utilization and (2) patient-centred ED care differs between DHH ASL-users and DHH English speakers. The first theme describes the social-behavioural processes through which DHH patients assess their need to use the ED. The second theme focuses on the social environment within the ED: patients feeling stereotyped, involvement in the care process, pain communication, receipt of accommodations and discharge processes.

CONCLUSIONS

This study underscores the importance of better understanding, and intervening in, DHH patient ED care-seeking and care delivery to improve patient outcomes. Like other studies, this study also finds that DHH patients are not a monolithic group and language status is an equity-relevant indicator. We also discuss recommendations for emergency medicine.

PATIENT OR PUBLIC CONTRIBUTION

This study convened a community advisory group made up of four DHH people to assist in developing research questions, data collection tools and validation of the analysis and interpretation of data. Community advisory group members who were interested in co-authorship are listed in the byline, with others in the acknowledgements. In addition, several academic-based co-authors are also deaf or hard of hearing.

Disability, an often-overlooked aspect of equity, diversity, and inclusion among radiology departments in Canada and the United States

PURPOSE

Despite nearly a quarter of Canadians and Americans reported to be living with a disability, persons with disabilities continue to face both physical and cultural barriers with respect to careers in medicine. Equity, diversity, and inclusion (EDI) statements can act as a first step in deconstruction of these cultural barriers. However, when compared to other EDI initiatives focused on gender, race, and ethnicity, persons with disabilities receive little attention.

METHODS

We conducted a cross-sectional analysis of all radiology residency program websites in Canada and the United States (US). Data was collected from each radiology department website including the presence or absence of an EDI statement or page; if present, we determined whether mention was made of persons with disabilities.

RESULTS

We reviewed the websites of 16 Canadian and 181 US radiology residency programs. Seven (44%) Canadian institutions had an EDI statement, with one (14%) mentioning persons with disabilities. In the US, 103 (57%) institutions had an EDI statement, with 42 (41%) mentioning persons with disabilities.

CONCLUSIONS

There were a significant proportion of radiology residency programs without EDI statements on their websites and an even smaller proportion that acknowledged persons with disabilities. An institution's public commitment to EDI, and specifically to patients and providers with disabilities, is central to implementing inclusive change going forward.

Impairment and Disability Identity and Perceptions of Trust, Respect, and Fairness

Importance

Most studies use impaired functioning alone to specify populations with disabilities. However, some people with functional impairments do not identify as disabled. With functional status-based definitions, studies have shown disparate care quality for people with disabilities.

Objective

To examine whether impairment and disability identity have different associations with perceived health care experiences and explore factors associated with disability identification.

Design, Setting, and Participants

This cross-sectional study used a nationally representative survey of US adults conducted from April 20 through May 31, 2021, and analyzed between June 1 and August 31, 2022. Survey participants were 1822 English- or Spanish-speaking adults responding either online or via telephone.

Exposures

Using 8 survey questions, participants were grouped according to presence of impairment and disability identity.

Main Outcomes and Measures

Likert scale measures of trust, respect, and fairness (henceforth, procedural justice measures) were dichotomized. Sociodemographic characteristics and rates of procedural justice responses were compared across groups. Multivariable logistic regressions adjusting for baseline characteristics were performed to (1) estimate associations of impairment and disability identity with perceptions of procedural justice and (2) explore factors associated with disability identification. Analyses applied survey weights.

Results

Of 6126 individuals invited to participate, 1854 (30.3%) completed the survey. Thirty-two were excluded due to unreportable gender, for a final analytic sample of 1822 participants. Participants with impairments (n = 816; mean [SD] age, 48.1 [17.0] years; 51.2% women, 48.8% men) had worse perceptions on 7 of 10 procedural justice measures (crude) compared with those without impairments (n = 1006; mean [SD] age, 49.6 [18.1] years, 55.1% female, 44.9% male). Among respondents with impairments, those who did (n = 340) vs did not (n = 476) identify as disabled gave better ratings for clinician communication efforts (a lot of effort, 38.8% vs 31.0%) and having health goals understood (understood very or fairly well, 77.2% vs 70.1%) but gave worse ratings for respect (almost never felt inferior or talked down to, 66.1% vs 59.1%). Disability identification was associated with more reports of unfair treatment (31.0% vs 22.4%; adjusted odds ratio, 1.65; 95% CI, 1.12-2.42) and of being unafraid to ask questions or disagree (50.5% vs 40.1%; adjusted odds ratio, 1.51; 95% CI, 1.04-20.19). Income and employment were associated with disability identification.

Conclusions and Relevance

In this cross-sectional survey study of US adults, health care perceptions differed between groups defined by impairment status and disability identity. These findings suggest that, alongside functional measures, health systems should capture disability identity to better address disparities for people with impairments.

ECHO autism adult healthcare: Training community clinicians to provide quality care for autistic adults

Autistic adults experience significant unmet healthcare needs, with opportunities for improvement in both the systems and the practitioners who serve this population. Primary care physicians/practitioners (PCPs) are a natural choice to provide comprehensive care to autistic adults but often lack experience in serving this population. This pilot study developed and tested an Extension for Community Healthcare Outcomes (ECHO) Autism model adapted from our previous work, focused specifically on training PCPs in best-practice care for autistic adults. The project was informed directly by the perspectives and preferences of autistic adults, caregivers, and PCPs. Two consecutive cohorts of PCPs participated in ECHO Autism Adult Healthcare sessions. Each cohort met 1 h twice a month for 6 months, with 37 PCPs (n = 20 in Cohort 1, and n = 17 in Cohort 2) participating. Based on findings from the first cohort, adjustments were made to refine the session preparation, curriculum, conduct of the ECHO, resources, and evaluation. After participation in the ECHO Autism program, PCP self-efficacy and satisfaction improved, while the number of perceived barriers did not change. Knowledge did not improve significantly in Cohort 1, but after adjustments to the training model, participants in Cohort 2 showed significant knowledge gains. While attention to systems of care is critical to addressing barriers in healthcare in the autistic population, the ECHO Autism Adult Healthcare model is feasible and holds promise for improving PCP satisfaction and self-efficacy in working with autistic adults.

Socioeconomic Characteristics, Lifestyle Behaviors, and Health Conditions Among Males of Reproductive Age With and Without Disabilities, NHANES 2013-2018

Health status during the reproductive years influences fecundity, fertility, and the future health of males and their offspring. There remains a dearth of literature examining men's preconception health, especially among high-risk populations, such as those with disabilities. The objective of this study was to examine indicators of preconception health, including chronic medical conditions, lifestyle behaviors, and health care utilization, among males of reproductive age with and without disabilities in the United States. Data were from 3,702 males of reproductive age (18-44 years) who participated in the National Health and Nutrition Examination Surveys, 2013-2018. Approximately 14% of males reported having at least one disability related to vision, hearing, cognition, mobility, self-care, or independent living. Among all men, suboptimal preconception health indicators were prevalent including poor or fair self-rated health; low education and household income status; lack of health insurance and no recent utilization of health care and dental care; cigarette smoking; frequent alcohol consumption and binge drinking; marijuana and illegal drug use; obesity; low fruit and vegetable intake and no multi-vitamin use; low physical activity; short sleep durations; depressive symptoms; and hypertension and asthma. Compared to males with no disabilities, males with any disabilities were more likely to have suboptimal preconception health indicators. Strategies to promote and improve sexual health, preconception care, and family planning services among all men are needed. For males with disabilities, specifically, further investigation of their specific health needs related to sex, reproduction, family planning, and fatherhood, as well as interactions with health care providers, is required.

From inequity to access: Evidence-based institutional practices to enhance care for individuals with disabilities

People with disabilities experience barriers to care in all facets of health care, from engaging with the provider in a clinical setting (attitudinal and communication barriers) to navigating a large institution in a complex health care environment (organizational and environmental barriers), culminating in significant health care disparities. Institutional policy, culture, and physical layout may be inadvertently fostering ableism, which can perpetuate health care inaccessibility and health disparities in the disability community. Here, we present evidence-based interventions at the provider and institutional levels to accommodate patients with hearing, vision, and intellectual disabilities. Institutional barriers can be met with strategies of universal design (i.e., accessible exam rooms and emergency alerts), maximizing electronic medical record accessibility/visibility, and institutional policy development to recognize and reduce discrimination. Barriers at the provider level can be met with dedicated training on care of patients with disabilities and implicit bias training specific to the surrounding patient demographics. Such efforts are crucial to ensuring equitable access to quality care for these patients.

After the Deluge: Leveraging Lessons from the COVID-19 Pandemic to Build the Trust of North Carolina's Disability Community

North Carolina's disability services infrastructure is biased toward institutional care, with inadequate funding and supply of home- and community-based services. The COVID-19 pandemic revealed dangers with this imbalance and provided the roadmap and motivation to fix it.

The capability imperative: Theorizing ableism in medical education

Medical education programs profess commitments to justice, equity, and inclusion, seeking to diversify the profession and better serve patient populations. Although disability has more recently joined recognized categories of valued diversity, significant barriers remain for disabled learners in medicine. This paper develops the concept of the capability imperative, derived from a constructivist grounded theory study examining disability inclusion at four U.S. medical schools that analyzed technical standards policies and interviews with 19 disabled students and 27 school officials (faculty and administrators). Through three motifs (the selfless superhuman; the "real world" of medicine; and the malleable student), the capability imperative enforces the characteristics of a good physician, justifies institutional arrangements, and seeks to produce a learner who can conform to these expectations. Drawing on critical disability theories of ableism and crip theory, the paper argues that the capability imperative represents a context-specific manifestation of ableism that upholds a cultural logic of compulsory hyper-ablebodiedness and mindedness. This logic is antithetical to inclusive goals. Exploration of what constitutes a physician and whom this vision serves may help to shift the professional culture towards justice and unroot disabled peoples' ongoing marginalization in the medical profession.

Making emergency medicine accessible for all: The what, why, and how of providing accommodations for learners and physicians with disabilities

Individuals with disabilities comprise a substantial portion of the U.S. population but make up only a small subset of medical students and health care providers. Both the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education have called for increased diversity in the physician workforce, to more closely represent the U.S. patient population and provide culturally effective care. Yet the barriers to disclosure and inclusion for individuals with disabilities in health care are significant, including attitudinal barriers such as stigma and bias, organizational barriers in policies and procedures, and environmental barriers such as resources and physical space. Lack of experience providing accommodations and a lack of knowledge of both what is legally required and what is possible also prevent programs from creating access. Realizing inclusion for individuals with disabilities in a diverse workforce requires emergency medicine programs to be proactive and deliberate in their approach to recruiting, accommodating, and retaining students, residents, and faculty with disabilities. Such efforts are likely to provide benefits that extend beyond those who receive the accommodations.

Accessible Medical Education & TIC: Increasing Equitable Care for Disabled Patients

An estimated 1 in 4 U.S. adults has a disability, and this number continues to increase. Disabled individuals face significant healthcare inequities, including but not limited to inaccessibility and mistreatment. Our current healthcare system is ill-equipped to provide equitable care to this population. There is a lack of accessibility in healthcare environments, lack of accessible medical training to enable disabled people to become healthcare providers serving their own community, and lack of thorough medical education that encompasses care for disabled patients. Furthermore, the increased risk of trauma, as well as increased risk of medical trauma specifically, endured by disabled people puts them at greater risk of long-lasting adverse effects. In this commentary, we analyze three key areas: 1) the current state of healthcare for disabled patients, 2) disability in medical education & physician workforce, and 3) the relationship between trauma and disability. We argue that the road to more equitable care for disabled patients involves changes to medical education that address all three of these areas. Medical training should expose trainees to disability early and throughout their training, should be made more accessible to support disabled physicians, and finally, should be trauma-informed in a manner that explicitly includes caring for disabled patients and their other intersecting identities.

Preconception Health and Disability Status Among Women of Reproductive Age Participating in the National Health and Nutrition Examination Surveys, 2013-2018

Background: Preconception health is a critical determinant of health outcomes for women and their offspring. Given higher rates of prenatal and postpartum complications among women with disabilities, it is important to investigate a range of preconception health indicators in this population. Materials and Methods: Data were from women of reproductive age (18-44 years) who participated in the National Health and Nutrition Examination Surveys, 2013-2018. Disability was self-reported as serious difficulty hearing, seeing, concentrating, walking, dressing, and/or running errands due to physical, mental, or emotional conditions. Preconception health indicators were adapted from those developed by the Core State Preconception Health Indicators Working Group. Multivariable Poisson regression estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals of preconception health indicators among women with disabilities compared with those without disabilities. Results: Of 4055 women, 601 (15%, weighted) reported having any disabilities, and of these women, 220 (6%) reported having 2 or more types of disabilities. Women with any disabilities were more likely to have suboptimal preconception health indicators compared with women without disabilities, including low education and household income, no recent dental visit, difficulty getting pregnant, current smoking, binge drinking, drug use, obesity, no multivitamin use, physical inactivity, long sleep durations, asthma, hypertension, and sexually transmitted infections (aPRs from 1.1 to 2.0). The greatest disparities between women with and without disabilities were for indicators of self-rated poor or fair general health, depression, and diabetes, with aPRs ranging from 2.4 to 3.8. Conclusions: Disparities in preconception health indicators are modifiable and may be addressed through adequate access to health care, interventions targeting lifestyle and health behaviors, and education and training for all health practitioners.