Realizing a Diverse and Inclusive Workforce: Equal Access for Residents With Disabilities

Improving access in medical physics residency programs for physicists with disabilities

Within the landscape of medical physics education, residency programs are instrumental in imparting hands-on training and experiential knowledge to early-career physicists. Ensuring access to educational opportunities for physicists with disabilities is a legal, ethical, and pragmatic requirement for programs, considering that a significant proportion of the United States population has a disability. Grounded in conceptual frameworks of competency-based medical education and the social model of disability, this work provides an introduction to some practical recommendations for medical physics residency programs. Strategies include embracing universal design principles, fostering partnerships with disability service offices, using inclusive language, developing and publicizing clear procedures for disclosing disabilities and requesting accommodations, and maintaining an overall commitment to equitable access to education. This work urges medical physics residency leadership to proactively move towards training environments that support the needs of residents across the spectrum of disability, highlighting why disability inclusion fundamentally enriches diversity.

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.

Identification and Accommodation of ADHD in Family Medicine Residencies: A CERA Study

BACKGROUND

An increasing number of medical students applying to residency programs request accommodations for attention deficit hyperactivity disorder (ADHD). Early implementation of accommodations for individuals with ADHD during family medicine (FM) residency could help learners and programs, but the number of programs prepared to invite learners to disclose ADHD and to implement accommodations is unclear.

OBJECTIVES

The purpose of this study was to describe practices employed by FM residency programs to identify residents who need accommodations for ADHD. We also chose to examine the frequency with which basic categories of ADHD accommodations are used and whether review of technical standards (ie, resident job description) is associated with timing of accommodations.

METHODS

We analyzed responses from the 2022 Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of FM residency program directors, which was distributed via email invitation to all US programs accredited by the Accreditation Council for Graduate Medical Education. A total of 298 program directors (44.3%) responded.

RESULTS

Approximately one in six FM residency programs are proactive in their identification of learners with ADHD, typically recognizing the need for accommodations during the interview process or orientation. Once the need is identified, most programs implement accommodations within 1 month, and many employ multiple types of accommodations.

CONCLUSIONS

While a small subset of programs has developed processes to identify and accommodate ADHD proactively, results suggested that the majority of programs approach accommodation processes on an ad hoc basis. In turn, ad hoc identification precludes a proactive approach, given use of poor performance to identify the need for supports.

Legibility: knowing disability in medical education inclusion

How medical students, their teachers, and school administrators understand disability appears connected to ongoing, unequal access to medical education for disabled people. The stigmatization of disability within medical education affects students' disability disclosures, yet few studies have explored how understandings of disability influence inclusion practices beyond individual student actions. This paper develops the concept of legibility, derived from a constructivist grounded theory study that examined disability inclusion at four U.S. medical schools through interviews with 19 disabled students and 27 school officials (faculty and administrators). With two dimensions (recognition and assessment of possibility), legibility demonstrates that knowing disability is relational, contextual, and equivocal. Drawing from the field of disability studies, the paper argues that the current paradigm of disability inclusion demands that students' disability experiences be highly legible to themselves and others, yet increased legibility comes with potential risk due to prevalent ableism. While individual interactions can shift understandings of disability towards greater inclusivity, systemic action that embeds liberating discourses of disability into medical education is needed.

What makes a 'good doctor'? A critical discourse analysis of perspectives from medical students with lived experience as patients

What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. We explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. We conducted 10 semistructured interviews with medical students with self-reported chronic illness or disability and who self-identified as patients. We used critical discourse analysis to code for dimensions of the 'good doctor'. In turn, using concepts of Bakhtinian intersubjectivity and the hidden curriculum we explored how these discourses related to student experiences with formal and informal curricular content.According to participants, dimensions of the 'good doctor' included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. Moreover, we identified two operating discourses of the 'good doctor': an institutionalised discourse of the 'able doctor' and a counterdiscourse of the 'doctor with lived experience' which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the 'good doctor' carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the 'good doctor' based on their experiences as patients, providing important considerations for curriculum and faculty development.

Strategies to Counteract Impact of Harmful Bias in Selection of Medical Residents

Human biases impact medical care in ways that perpetuate health disparities. Research has demonstrated that biases negatively affect patient outcomes and stifle diversity across the physician workforce, further compounding health disparities by worsening patient-physician concordance. Taken as one, the application, interview, recruitment, and selection processes employed by residency programs has been one of the critical junctures where bias has exacerbated inequities among future physicians. In this article, the authors define diversity and bias, review the history of bias in residency programs' processes for selecting residents, explore the impact of this history on workforce demographics, and discuss ways to optimize and work toward equity in the practices used by residency programs to select residents.

Words matter: Tracing the implicit meaning of diversity language (and its absence) in medical school mission statements

Despite recent attention to social justice, diversity, equity, and inclusion within medical education, little is currently known about whether and to what extent that attention has translated into the language of formal documents articulating organization purpose: medical school mission statements. Mission statements are the marquee declaration of a medical school's identity and purpose, and a recommended tool for applicants to determine "fit" when applying. This study examines whether and to what extent social justice, diversity, equity, and inclusion have made it into the formal public statements of organizational purpose and identity over the last several years. Mission statements were extracted manually from the 2007, 2017, and 2021 AAMCs Medical School Admission Requirements (MSAR) database for both U.S. and Canadian M.D. granting medical schools. Then each mission statement version was coded for the presence and degree of diversity language including words like social justice, diversity, equity, and inclusion using an agreed-upon lexicon. Frequencies and within school changes over time were analyzed. Among 139 medical schools with discoverable mission statements from 2007, 91% (n=127) changed their MSs between 2007 and 2021. In 2007, 24% (n=33) of MSs contained diversity language. By 2017 nearly half of MSs; 47% (n=65) contained any reference to such language. But by 2021, despite 46 school having changed their MSs again, only a few more included diversity language in their MSs (56%; n=77). The most common terms used were "diversity," followed by the increasing presence of words like "inclusion," "equity," and "justice" by 2021. Curiously, a few schools redacted diversity language from 2007 to 2021. A Diversity Thesaurus of 22 terms was iteratively identified, with all terms searched in all MSs. Overall, mission statement change was quite common with most medical schools making changes across the 14 years covered in this study. And despite a doubling of the number of medical schools MSs mentioning diversity over a 10-year period, that increase seemed to slow in recent years even among schools who had a chance to change their MS. As of mid-2021, two in five US medical schools still have no mention of diversity related language in their most formal, said articulation of organizational purpose.

Innovation management involvement among persons with disabilities in Malaysia

Background: As Malaysia struggles with the battle to retain talented workers, the retention of persons with disabilities (PWDs) remains a major challenge in innovation management. Malaysia currently has the lowest retention of PWDs in innovation management in The Association of Southeast Asian Nations (ASEAN). The purpose of this study is to develop a unique framework to enhance the inclusion of PWDs in Malaysia. 

Methods: A questionnaire was distributed to 200 PWDs in the central region of Malaysia.  

Results: Based on the results of this research, four crucial variables (salary, compensation, career advancement and reward management) contributed to the lack of involvement in innovation management among PWDs in Malaysia. 

Conclusions: This study focuses on 200 PWDs in Malaysia. Despite the fact that PWDs’ involvement in innovation management is the lowest, there is a lack of research initiative and practitioner commitment to address this issue. Serving as preliminary research in Malaysia, this study develops a unique framework to fill the gap.

This is My Learner, Not My Patient: Addressing Concerns in Learners With Attention Deficit Hyperactivity Disorder

With the increasing number of medical students diagnosed with adult ADHD, residency programs face an imperative task to handle accommodations effectively. As medical residents occupy unique roles as learners and employees, defining a clear process to protect residents and programs can be challenging. This article will review legal requirements, disclosure processes, and sample accommodations that can help family medicine programs make sense of their responsibilities and support residents. Collaboration, clear boundaries, and effective documentation increase the likelihood of a predictable process to facilitate inclusion of learners with ADHD into graduate medical education and residency.

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.

Exploring accommodations along the education to employment pathway for deaf and hard of hearing healthcare professionals

BACKGROUND

Deaf and hard of hearing (DHH) people are an underserved population and underrepresented among healthcare professionals. A major barrier to success for DHH healthcare professionals is obtaining effective accommodations during education and employment. Our objective: describe DHH individuals' experiences with accommodations in healthcare education.

METHODS

We used an online survey and multipronged snowball sampling to recruit participants who identify as DHH and who had applied to a U.S. health professional school (regardless of acceptance status). One hundred forty-eight individuals representing multiple professions responded; 51 had completed their training. Over 80% had been accepted to, were currently enrolled, or had completed health professions schools or residency programs, and/or were employed. The survey included questions addressing experiences applying to health professions programs and employment; satisfaction with accommodations in school and training; having worked with a disability resource professional (DRP); and depression screening.

RESULTS

Use and type of accommodation varied widely. While in school, respondents reported spending a mean of 2.1 h weekly managing their accommodations. Only 50% were highly satisfied with the accommodations provided by their programs. Use of disability resource providers (DRPs) for accommodations was highest during school (56%) and less frequent during post-graduate training (20%) and employment (14%). Respondents who transitioned directly from school to employment (versus via additional training) were more satisfied with their accommodations during school and were more likely to find employment (p = 0.02). Seventeen respondents screened positive for risk of depression; a positive screen was statistically associated with lower school accommodation satisfaction.

CONCLUSIONS

DHH people study and practice across many health professions. While respondents were mostly successful in entering health professions programs, accommodation experiences and satisfaction varied. Satisfaction with accommodations was related to successful employment and wellness. Low satisfaction was associated with higher likelihood of depression symptoms. To increase representation in the workforce, healthcare professional schools, training programs, and employers should enhance support for the learning and working climates for people with disabilities.

Learners With Disabilities: An Important Component of Diversity, Equity, and Inclusion in Medical Education

The population of people with physical or sensory disabilities is growing, yet they are underrepresented in the medical and other health professions. At the same time, there is a clear need to enhance didactic curricular content and clinical training experiences that explicitly address the full scope of medical needs that individuals with disabilities have. These gaps represent missed opportunities to advance the health of an important, underserved, and growing population. Based on the authors' experience, the inclusion of people with physical or sensory disabilities in medical education greatly enhances the education of all learners and the professional development of faculty and staff, providing invaluable perspectives on the significant abilities of individuals with diverse physical or sensory disabilities. There are additional efforts and costs associated with the education of a medical student who is blind, is deaf, uses a wheelchair, or has another disability. But based on the authors' experience, it is clear that the societal return on investment is enormous, and the costs associated with a failure to embrace full inclusivity are much greater. Medical education institutions should recognize the population of people with disabilities as a vital component of their commitment to diversity, equity, and inclusion and strive to provide inclusive education for learners with disabilities.

Outcomes From a Novel Graduate Medical Education Leadership Program in Advancing Diversity, Equity, and Inclusion

BACKGROUND

Academic medicine needs more diverse leadership from racial/ethnic minorities, women, people with disabilities, and LGBTQIA+ physicians. Longitudinal structural support programs that bring together underrepresented in medicine (UiM) and non-UiM trainees are one approach to build leadership and scholarship capacity in diversity, equity, and inclusion (DEI).

OBJECTIVE

To describe the creation, satisfaction with, and feasibility of a Leadership Education in Advancing Diversity (LEAD) Program and evaluate scholars' changes in self-efficacy, intended and actual behavior change, and outputs in leadership and DEI scholarship.

METHODS

In 2017, we created the LEAD Program, a 10-month longitudinal, single institution program that provides residents and fellows ("scholars") across graduate medical education (GME) with leadership training and mentorship in creating DEI-focused scholarship. In the first 3 cohorts (2017-2020), we assessed scholars' self-efficacy, actual and planned behavior change, and program satisfaction using IRB-approved, de-identified retrospective pre-/post-surveys. We measured scholarship as the number of workshops presented and publications developed by the LEAD scholars. We used descriptive statistics and paired 2-tailed t tests to analyze the data.

RESULTS

Seventy-five trainees completed LEAD; 99% (74 of 75) completed the retrospective pre-/post-surveys. There was statistically significant improvement in scholars' self-efficacy for all learning objectives. All trainees thought LEAD should continue. LEAD scholars have created workshops and presented at local, regional, and national conferences, as well published their findings. Scholars identified the greatest benefits as mentorship, developing friendships with UiM and ally peers outside of their subspecialty, and confidence in public speaking.

CONCLUSIONS

LEAD is an innovative, feasible GME-wide model to improve resident and fellow self-efficacy and behaviors in DEI scholarship and leadership.

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

OBJECTIVES

Individuals with disabilities experience significant health care disparities due to a multitude of barriers to effective care, which include a lack of adequate physician training on this topic and negative attitudes of physicians. This results in disparities through inadequate physical examination and diagnostic testing, withholding or inferior treatment, and neglecting preventative care. While much has been published about disability education in undergraduate medical education, little is known about the current state of disability education in emergency medicine (EM) residency programs.

METHODS

In 2019, a total of 237 EM residency program directors (PDs) in the United States were surveyed about the actual and desired number of hours of disability health instruction, perceived barriers to disability health education, prevalence of residents and faculty with disabilities, and confidence in providing accommodations to residents with disabilities.

RESULTS

A total of 104 surveys were completed (104/237, 43.9% response rate); 43% of respondents included disability-specific content in their residency curricula for an average of 1.5 total hours annually, in contrast to average desired hours of 4.16 hours. Reported barriers to disability health education included lack of time and lack of faculty expertise. A minority of residency programs have faculty members (13.5%) or residents (26%) with disabilities. The prevalence of EM residents with disabilities was 4.02%. Programs with residents with disabilities reported more hours devoted to disability curricula (5 hours vs 1.54 hours, p = 0.017) and increased confidence in providing workplace accommodations for certain disabilities including mobility disability (p = 0.002), chronic health conditions (p = 0.022), and psychological disabilities (p = 0.018).

CONCLUSIONS

A minority of EM PDs in our study included disability health content in their residency curricula. The presence of faculty and residents with disabilities is associated with positive effects on training programs, including a greater number of hours devoted to disability health education and greater confidence in accommodating learners with disabilities. To reduce health care disparities for patients with disabilities, we recommend that a dedicated disability health curriculum be integrated into all aspects of the EM residency curriculum, including lectures, journal clubs, and simulations and include direct interaction with individuals with disabilities. We further recommend that disability be recognized as an aspect of diversity when hiring faculty and recruiting residents to EM programs, to address this training gap and to promote a diverse and inclusive learning environment.

"I Can Understand Where They're Coming From": How Clinicians' Disability Experiences Shape Their Interaction With Clients

Students and clinicians with disabilities are underrepresented in the academic health programs and professional clinical settings. Disability studies foregrounds the unique ways of knowing and being that clinicians with disabilities can offer. Based on a larger grounded theory study of the experiences of students and clinicians with disabilities, this article examines the role that clinicians' abilities to draw on their personal experiences of living with a disability have on their interactions with clients. The analysis of semistructured interviews with 55 students and clinicians with disabilities from different fields contributes to the development of a theory of epistemic connection. The theory is informed by the following three themes: (a) building rapport through understanding, (b) from understanding to advocacy and creative approaches, and (c) between professionalism and disability. The findings emphasize not only the importance of diversifying the health care workforce but also incorporating disability epistemology into the health care culture.

The Unexamined Diversity: Disability Policies and Practices in US Graduate Medical Education Programs

BACKGROUND

Graduate medical education (GME) institutions must ensure equal access for trainees with disabilities through appropriate and reasonable accommodations and policies. To date, no comprehensive review of the availability and inclusiveness of GME policies for residents with disabilities exists.

OBJECTIVE

We examined institutions' compliance with Accreditation Council for Graduate Medical Education (ACGME) requirements and alignment with Association of American Medical Colleges (AAMC) policy considerations.

METHODS

Between June and August 2019, we conducted a directed content analysis of GME institutional policies using the AAMC report on disability considerations and the ACGME institutional requirements as a framework.

RESULTS

Of the 47 GME handbooks available for review, 32 (68%) included a disability policy. Forty-one of the 47 (87%) handbooks maintained a nondiscrimination statement that included disability. Twelve of the 32 (38%) handbooks included a specific disability policy and language that encouraged disclosure, and 17 (53%) included a statement about the confidential documentation used to determine reasonable accommodations. Nineteen of the 32 (59%) maintained a clear procedure for disclosing disabilities and requesting accommodations.

CONCLUSIONS

While disability policies are present in many of the largest GME institutions, it is not yet a standardized practice. For institutions maintaining a disability policy, many lack key elements identified as best practices in the AAMC considerations.

Emergency Medicine Resident Education on Caring for Patients With Disabilities: A Call to Action

People with disabilities constitute a marginalized population who experience significant health care disparities resulting from structural, socioeconomic, and attitudinal barriers to accessing health care. It has been reported that education on the care of marginalized groups helps to improve awareness, patient-provider rapport, and patient satisfaction. Yet, emergency medicine (EM) residency education on care for people with disabilities may be lacking. The goal of this paper is to review the current state of health care for patients with disabilities, review the current state of undergraduate and graduate medical education on the care of patients with disabilities, and provide suggestions for an improved EM residency curriculum that includes education on the care for patients with disabilities.