AAMC Reporter, July 2000: Blind Medical Student Beats the Odds

VOLUME 9, NUMBER 10

JORDAN J. COHEN, M.D., PRESIDENT

JULY 2000

Blind Medical Student Beats the Odds

by Gina Shaw

"You can't do that." It's a statement Tim Cordes has heard a lot in his 24 years. When he wanted to ride a bike or a skateboard. When he wanted to study ju-jitsu. When he wanted to major in biology at the University of Notre Dame. And when he wanted to go to medical school.

Tim Cordes is blind. He lost his vision gradually as a child to a degen- erative condition called Leber's disease. Early on, a pediatric ophthalmologist told Tim's parents not to expect much, listing all the things he would not be able to do. Other doctors offered the same advice-advice that Tim's parents thoroughly ignored, letting him play as hard as any child and making up their minds early on not to join the chorus of people saying, "Tim, you can't do that!"

Tim spent his youth making believers out of the "you can't do that" crowd, graduating from Notre Dame University as valedictorian with a 3.99 grade-point average, earning black belts in ju-jitsu and tae kwon do, and becoming an adept water skier and canoeist. But when he applied to medical school, at first it appeared that this time the people who said, "You can't do that," were right.

Only two other blind students had ever graduated from medical school: David Hartman, who graduated from Temple in 1976 and now practices psychiatry in Virginia, and a young woman who recently graduated from the University of Colorado who's now in residency. Tim applied to eight medical schools and collected a stack of rejections … until the University of Wisconsin School of Medicine told him that he would be one of 143 students in its entering class for 1998.

That was two years ago. Tim recently wrapped up finals for his second year at Wisconsin, and he and his German shepherd, Electra, have become well-known on campus. Tim's drive, self-possession, and problem-solving skills make what he's achieved look easy-but it hasn't been, either for him or for the medical school.

Treating What You Can't See

One of the first questions people ask when they hear about a blind medical student-or a blind physician-is, "How can you treat patients you can't see?" Medical educators think at a far more fundamental level. How can you learn cell biology when you can't see the slides? How can you dissect a cadaver when you can't see what you're dissecting?

Modern technology, say all the professors and university officials who've worked with Tim, has made this seemingly insurmountable obstacle a lot less daunting. "We've converted all the school-produced course material into an electronic format, and Tim uses a program to convert material into sound," explains Mike Moninger, director of Student Academic Development. "We convert all line drawings into raised line drawings. With microscopic images, we create line drawings and convert them to raised images." While creating many of these materials is technologically simple, Moninger says, it eats faculty time like a teenager eats cheeseburgers.

And not all the image conversion is so straightforward. Changing a microscopic image, which by nature is visual, into a different format poses serious challenges. "How can you describe a microscopic image of cancer in situ? Can it be converted to a line drawing, and even if it can, is the line drawing equivalent?" asks Moninger. "At all times, we tried to make the image representations as equivalent as possible to the normal examination."

If something just can't be converted, Tim uses a visual describer. For example, in his first-year anatomy class, a second-year student narrated the exploration of the cadaver as Tim felt his way through the body. Since anatomy is very much a tactile as well as a visual science, figuring out what he was "seeing" wasn't as difficult for Tim as many might have expected. Mikel Snow, M.D., associate dean of students and Tim's anatomy instructor, says that Tim frequently astonished him with his perception, earning a well-deserved A in the course. During one lecture on the muscles of the eye, Dr. Snow used a Styrofoam model to illustrate, then asked a series of questions. Each time, the correct answer-after silence from the other baffled students-came from Tim. "I had 15 students see this model who couldn't get it-but he did," recalls Dr. Snow.

While the system they've worked out at Wisconsin might not work for every blind student who wants to study medicine, it certainly has worked for Tim, says Rick Moss, Ph.D., professor and chair of Physiology. "Tim is especially adept at interpreting images," Dr. Moss says. "That came through very clearly on examinations."

Tim ranks near the top of his class. And despite some predictions, he hasn't required a lot of extra help outside of class. "Tim came to my office a few times, but by no means was he the most frequent visitor. He came to ask questions not so much of clarification, but of extension of material-he was thinking beyond the material," Dr. Moss notes. "While many students were looking for clarification, he would come in and ask the next obvious question from a scientific standpoint."

New Challenges in the Clinical Setting

Moninger, who directs the adaptations Wisconsin makes on Tim's behalf, thinks they'll be up against a more perplexing set of challenges when he goes from the largely in-class environment of the first two years of medical school into the clinical setting of third- and fourth-year studies. "Huge adaptations will have to be made as Tim enters his third year and is seeing patients on a regular basis," Moninger explains. The issues they expect to confront include adaptations for Tim's dog, Electra, mobility around unfamiliar places, and special equipment such as blood pressure cuffs. "The readout can't be visual-it has to be tactile or auditory in some way."

Tim, as always, is pragmatic but optimistic. He predicts charting will be one of the most difficult issues to handle but already has some ideas for how he'll get around that barrier. "The way charting's done now is pretty inaccessible to me," he says. "I'm thinking about working out an arrangement with other house-staff or nurses, or hiring someone to read charts at certain times every day."

And he's already experimented with equipment like the auditory blood pressure cuff during patient exams in some of the three or four half-day clinic visits Wisconsin first- and second-year students do each semester. Patients in the clinics have reacted positively so far, Tim says, occasionally asking how he can do things like check blood pressure without seeing the cuff. Electra has also been a big help. "Sometimes she helps build rapport with the patient. Her presence puts people at ease," Tim says. Tim and his friends have also practiced adaptations for taking patient histories, reading charts, and other elements of the clinical encounter. "When an average physician asks someone to demonstrate their range of motion to assess their joint mobility, that physician might stand back and watch the movement," Tim says. "We worked out how I can hold onto someone's wrist and feel their range of motion while they are bending their arm or flexing their elbow."

They'll have time to develop a few more solutions before Tim is in the clinic full-time. As an M.D.-Ph.D. student, he'll be doing his research first. "We have a small reprieve," says Moninger, who plans to go with Tim into several clinical situations and experiment with what's possible. "We define the objectives, define the learned skills for the student, and then try to accommodate for each skill that has to be learned," Moninger explains. "So far we've been doing all the adaptations he's been accustomed to all his acade-mic life, but now we're moving into unfamiliar territory."

Tim hopes that the rapid pace of technological advances will work in his favor. "Pie in the sky, I'm hoping that a lot of charting in four years will be more electronic, which I think there's a good chance of," Tim says. In fact, his extensive electronic tracking of lecture notes and other materials has already made Tim a very popular guy. "I can carry around a five-pound computer with all the lectures I've had in medical school to date, and a textbook on internal medicine and 20 other books stored inside it," he says. "When we're working in groups, my friends will often ask me, 'What did we learn about this again?' because they know all my notes are accessible any time." Tim's computer reads text to him at 500 words a minute.

Lessons Learned

One of the most important lessons he's learned in working with Tim, says Moninger, is that blind students are no more alike than sighted students are. When Tim first came to campus, they consulted with the medical student from the University of Colorado but found that much of her experience wasn't applicable. "Tim relies heavily on the machine that converts text to auditory material, and she didn't find that as useful as Tim has found it. She relied a lot on visual describers, while Tim prefers not to," Moninger says.

"Although you might have two blind students in the same time and space, the learning styles could be entirely different and then the requested accommodations would be different as well." In other words, he says, "You can't say, 'I've learned how to accommodate a blind student.' You can only say, 'I've learned how to accommodate this blind student.'"

Because the process of developing these accommodations doesn't lend itself to automation and standardization, it's also very time-intensive. That's lesson No. 2 for the next school that works with a blind medical student, Moninger says. "Converting images and creating tools requires immense cognitive skills from your faculty and staff. It's not a process for ignorant people." While the system can't be standardized, Moninger does admit that making adaptations gets easier. "You develop a repertoire of solutions and try them out. The challenge in the school is to match the accommodation to the disability and to the person."

Tim has nothing but praise for the work Wisconsin has done to make his medical education possible. It may have been the only school that accepted him, but now he's glad he didn't end up anywhere else. "I'm really happy I came to Wisconsin," he says. "Their attitude is 'We can do this, and let's figure out how.' That's been really helpful, and the faculty have been very supportive."

For the next three or four years, Tim will focus on his research goals. His specialty: protein structure work. "We know a lot about the genetic sequences for proteins, but we know far less about what the protein looks like in 3-D once it's been made," he says. Tim hasn't selected a specialty yet or decided what type of residency he might pursue, although a career in medical research is a strong possibility.

Tim doesn't think of himself as an inspiration, says Dr. Moss, but others certainly do. "The term role model definitely applies," he says. "I would be a little hesitant to draw an overarching conclusion, but our experience with Tim has been nothing but positive. From our standpoint, this would certainly be a stimulus to bringing in similar students in the future."

22 March 2001