A Word From the President

Reconsidering "Disabled" Applicants

Seventy-two years ago, a young woman in Dallas, Texas claimed her space in history by opening her own medical office and becoming the first practicing female orthopedist in the United States. One year later, Ruth Jackson, M.D., applied for membership at the newly founded American Academy of Orthopaedic Surgeons (AAOS) and was bluntly denied admission. It is not very difficult to speculate on the reasons for her rejection.

A diminutive woman standing at 4 feet and 10 inches, Dr. Jackson eventually moved on to defy several stereotypes regarding women's supposed inability to succeed in medical specialties that required, at the time, a good measure of physical strength. She became board certified four years after opening her practice and eventually did become the first woman admitted to the AAOS.

The bias against women in medicine was based on mental models about how the world should work and who was fit for the profession. Currently, other sets of mental models affect our thinking about who is qualified to practice medicine such as age, race or physical ability. Arguments similar to the ones used in the past against women's entrance into the so-called "manly" specialties have appeared recently to discourage persons with disabilities from entering medical school. These arguments touch at the core of profound questions regarding the nature of our profession and of the medical education process.

The Americans with Disabilities Act (ADA) defines a disabled person as someone with a physical or mental impairment that substantially limits one or more major life activities. According to the law, to be considered disabled the person must have a current impairment, have a record of impairment, or be regarded by others as actually having the impairment. Both public and private entities are required to provide accommodations to persons with disabilities so that they may enjoy the same benefits, services and opportunities as those without disabilities. In particular, during their admission processes, medical schools and other institutions of higher education are required to judge students on the basis of their capacity to complete the educational program, rather than on their status as disabled persons.

According to the ADA, students seeking admission to medical school must be able to perform the "essential functions" or meet the "essential eligibility requirements" of the program after being provided with the needed accommodations. Each school is responsible for determining the "essential functions" or "essential eligibility" requirements (i.e., "technical standards") of its educational program, and for establishing its admissions criteria with such definitions in mind. For example, a requested accommodation that would cause a school to fundamentally alter its curriculum is not a reasonable accommodation. Additionally, of course, when deciding whe- ther or not to admit a student with a disability, the reasonable accommodations required by the ADA cannot create an undue hardship for the institution. Schools obviously vary in their ability, financially and otherwise, to implement reasonable accommodations even if their technical requirements would permit the admission of a given student.

Determining the fundamental req-uirements of a medical school program entails more than a simple legal or curricular design exercise. When contem- plating such requirements, one is challenged to answer several questions, including: what does it means to be a doctor in today's society; what constitutes good doctoring; and what are the truly non-negotiable elements composing a basic medical education.

Take the hypothetical example of a straight "A" student with high MCAT scores who possesses all the intellectual and personal characteristics expected of doctors but who happens to be quadriplegic. The admissions officers review- ing such an application would need to determine whether their institution's essential eligibility requirements dictate that all students be able to perform certain activities that only the physically "unimpaired" are able to perform unaided, such as a complete physical examination and resuscitation procedures. In framing their requirements, institutions need to consider not only societal expectations of doctors but also how doctors are actually practicing in today's workplace.

Here is an even more basic ques-tion: should medical schools enroll only those students who appear to have the potential to enter any existing field of medicine, or should schools be able to admit students whose limited abilities would clearly preclude their pursuit of some options? In other words, should we consider abandoning the concept of the "undifferentiated graduate," which assumes that all students have acquired the knowledge and skills required to enter any kind of residency? One can make a strong argument, it seems to me, that the "market" for residency positions (rather than the medical school admissions process) should be relied upon to ensure that only students possessing relevant physical abilities (e.g., adequate eyesight) end up in fields (e.g., surgery) requiring those abilities.

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. 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.

With this thought in mind, the AAMC is in the process of updating the advisory materials it prepared to provide guidance to our constituents after the enactment of the ADA in 1990. The updated version is intended to assist those medical schools that wish to review and refine their institutional policies and will provide an overview of relevant legal considerations including lessons learned from case law over the past decade. These matters will be discussed at this month's GSA Joint Professional Development Conference for Admissions, Minority Affairs and Student Records Officers where we are certain to get useful feedback.

Considering the merits of a medical school applicant with a disability is not merely a matter of being ADA compliant. It's about being faithful to one of our most fundamental obligations: deciding who among the host of eager applicants are best equipped to serve the health care needs of our country.

Jordan J. Cohen, M.D.
AAMC President

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