AAMC Reporter: February 2006

Joel A. DeLisa, M.D., M.S. Professor and Chair, Physical Medicine and Rehabilitation UMDNJ-New Jersey Medical School President & CEO Kessler Medical Rehabilitation Research and Education Corp.

Viewpoint: "Physicians With Disabilities: Why Aren't There More of Them?"

Although people with disabilities make up about 20 percent of the nation's population, only a tiny fraction of medical school matriculants have disabilities. Why? First, let's consider some relevant history from the AAMC itself.

In 1997, AAMC President Jordan J. Cohen, M.D., issued a moral charge to the medical profession. Writing in Academic Medicine, he called for "active steps to ensure that our health care practitioner community mirrors society's gender, racial, and ethnic mix." In a more recent essay, in the June 2004 AAMC Reporter, Cohen expanded the scope of the issue beyond considerations of race, ethnicity, and gender to include disability.

"Technological advances have made a host of things possible, both in medicine and in virtually every other walk of life, that were way beyond many people's abilities not so long ago," Cohen observed. "Compelling examples of individuals, albeit still relatively few in number, with mobility, auditory, and visual disabilities who are valued members of the profession argue that it's time to reconsider our traditional, often stereotypic, view of what it takes to be a capable doctor."

Significantly, the recently released and widely supported "Compact Between Resident Physicians and Their Teachers," drafted by the AAMC, also includes the disability issue. Among 10 faculty commitments in the document is this one: "We will demonstrate respect for all residents as individuals, without regard to gender, race, national origin, religion, disability, or sexual orientation."

So why don't we have more physicians with disabilities? In my experience, no American medical school has a "welcome sign" for individuals with physical disabilities. We need to do much more.

In an article in the January 2005 American Journal of Physical Medicine & Rehabilitation, I discussed the need to reassess our policies regarding physicians with disabilities and the physician workforce and made recommendations to the AAMC on how current policies could be changed to achieve this goal. I argued that medical schools' core competencies and technical standards have not kept pace with technological changes, diverse specialization, and changing practice options.

A recent AAMC publication, "Medical Students With Disabilities: A Generation of Practice," offers the medical education community a practical guide for furthering its work with students with disabilities. But I believe that some of the report's analysis and recommendations carry a negative and less-than-constructive tone. I am especially concerned about language meant to guide universities in their treatment of students with disabilities that could be better categorized as a guide to keep physically disabled applicants out.

One key issue concerns the so-called undifferentiated curriculum versus the undifferentiated student. I favor the undifferentiated curriculum.

Medical specialization has segmented the physician workforce — from a more homogenous group into one concentrating on specific body systems or disease entities. That is the reality of practice in the United States. My view is that significant differentiation of physicians into various specialties and subspecialties can serve as an argument for less rigidity in demanding that all students demonstrate competence in procedures that are not relevant to their expected practices.

The undifferentiated curriculum would allow students to meet competency requirements through multiple options, even including the role of physician extender, or mid-level health care provider. But I absolutely oppose using a tracking system, in which someone is admitted to medical school under the presumption that he or she will be designated to a specific postgraduate specialty. Each student must be handled on a case-by-case basis. The resident interviews by each specialty can handle that issue.

Clearly, admitting someone with a physical disability to medical school is controversial. In training competent physicians, we must protect both the well-being of all patients and the rights of all trainees. All medical students must have the appropriate intellectual capacity, ethical attitude, humanistic qualities, and desire to become doctors.

At the same time, we must respect creative solutions that people with disabilities often employ to perform tasks in alternate ways. The ability to perform the task at a defined level of quality should be emphasized, rather than the process by which the task is accomplished. We need to be flexible and consider what is possible through hard work and the use of technology.

The need for program modifications and reasonable accommodations differs for students, residents, and faculty members. A student's focus is on educational requirements and on meeting the diverse demands of the basic sciences and clinical years. Faculty members with disabilities tailor their practices to minimize the need for accommodations, and organized medicine accepts and readily supports this.

Residency, however, is truly a mixture of service and education, and it offers perhaps the greatest challenges in terms of disability considerations. Residents may need to perform certain services essential to their residency program that are not necessary for students or faculty members. Even within a specialty, not all programs have the same "service" requirements. Should this work obligation be a barrier to satisfactory completion of residency training?

These issues must be studied; they will not go away. If diversity is an essential goal, as it should be, we must work to reach it. Otherwise, it could be said that we, as medical educators, are part of the problem.

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