People with Disabilities Can (and Should) Pursue a Career in Medicine

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Mari Knettle:

Hi, welcome to today's episode of MedEd Thread. I am your host, Dr. Mari Knettle, Medical Director of the Center for Health Professions Education here at Cleveland Clinic. Today, I'm very pleased to have Rachel King join us. Rachel is the Director of Educational Equity at Cleveland Clinic, and she serves as its section 504 coordinator. Rachel, welcome.

Rachel King:

Thank you. I'm happy to be here.

Dr. Mari Knettle:

Tell me a little bit about your professional background.

Rachel King:

So, I'm an attorney and I have a higher education and compliance background.

Dr. Mari Knettle:

And what do you do here at Cleveland Clinic?

Rachel King:

So, I'm the director of educational equity, which means that I address reports of discrimination and harassment in our educational programs. And then I serve as the clinic section 504 coordinator. Section 504 of the rehabilitation act of 1973 predated the ADA, and it prohibits discrimination against individuals with disabilities in institutions that receive any federal money.

Dr. Mari Knettle:

So why do you think it's important for us to talk about disability accommodation in medical education?

Rachel King:

So, I think there are a number of reasons. I think as a profession, we want to be inclusive and obviously including individuals with disabilities is a part of that. Then we're, we strive to reduce or eliminate healthcare disparities. And the research shows that individuals with disabilities are one of the most underserved communities in healthcare. And so having healthcare providers who have disabilities will help close that gap a little bit.

As employers and as an industry, we are predicting that there's gonna be a shortage of healthcare workers. And so again, individuals with disabilities are one of the, have one of the highest unemployment rates. And so, there are resources that are available for us to tap. And then we have a legal obligation to ensure that we are providing accommodations to individuals with disabilities, if we can do so, if we can provide them reasonable accommodations that allow them to perform their jobs or perform in their academic programs.

Dr. Mari Knettle:

I know that back when I was a student or when I was teaching, I was very well aware, as were other students and my colleagues in teaching, we were all very aware that students with disabilities were able to be accommodated in our educational programs. But I think that there were always questions about how that applied to our medical programs or some of our more hands-on type professions, even outside of medicine. Do you think that there is a widespread perception that individuals with disabilities can't pursue a career in healthcare?

Rachel King:

I think there is. And I think it comes from just in general in society or in the us, you have a perception of a healthcare worker as being kind of a, a superhuman person with no frailties. And I think that carries over to thinking that individuals with disabilities may not be able to perform in healthcare. Then I think also many disabilities are invisible. You don't know people have them, so people might not be aware that their healthcare provider has a disability. I also think that the folks who work in disability accommodations in higher education don't usually have experience in clinical backgrounds, and so they may not really understand how the requirements apply in a clinical setting.

So, I do think in general, it is seen as a barrier. I think students may not know what to expect in a clinical setting. The disability services folks that they work with may not understand the clinical setting. And then in general, if you sort of add all of that together, along with the general perception that healthcare providers should be able to do everything, it- it makes for a perception that individuals with disabilities can't go into healthcare.

Dr. Mari Knettle:

So clearly there is a misperception that individuals with disabilities can't pursue a career in medicine, but who really has that misperception? Is it the student? Is it the faculty member? Is it the public or where is this coming from?

Rachel King:

I think there's overall a general fear that an individual with a disability won't provide the same level of patient care as someone without a disability. I think that is often the initial reaction of a faculty member, for example, or a preceptor when they're faced with a request for accommodation. I think students fear that they are going to be judged if they reveal- you know, they don't know exactly who's gonna know about it. What are their peers gonna think? What are their leaders gonna think? So, I think there's, it's less that they think they aren't capable so much as they think they don't want people to know if they have a disability. And then again, the public, you know, has the same kind of is subjected to the same kind of, you know, media messages and stereotypes. And so, they may consider seeing an individual with a disability, providing their patient care. If they're patients as kind of unexpected.

Dr. Mari Knettle:

I recently read an article that shocked me about patients with disabilities and physical therapists, which I am one. It was written in the context of physical therapy that we have a lot of work to do for providing care for patients who have disabilities. So, I wonder if the misperception about abilities of individuals, I don't know, it's just so per pervasive that it it's impacting all of patient care. Would this be a problem that we could solve? Would it have an impact on patients if we improve that misperception?

Rachel King:

Yeah. I mean, I think in several different ways, I think healthcare providers who worked with peers that had disabilities would have a much better understanding of the experience of an individual with a disability. I think like many underserved communities, individuals with disabilities are often subjected to stereotypes from their providers, which is incredibly unfortunate, and particularly for providers who work with individuals with disabilities, sort of constantly, but I think pretty much all the research shows that it's an underserved community and this is why. And I think for all of us, if we see a healthcare provider who looks like us, who is like us and you know, our race, our religion, our gender, I think that makes it easier for us to seek and receive healthcare, and that's true for individuals with disabilities as well.

Dr. Mari Knettle:

So, when we're having conversations about diversity equity and inclusion, does the topic of disability accommodation need to be part of that bigger conversation we're having about DEI?

Rachel King:

Yeah, it should be. And I've seen actually recently DEIA, which is diversity, equity, inclusion, and access. But I think there's, you know, individuals with disabilities are an underserved community, just like other underserved communities that we want to provide access to, or we want to include in our profession. They're in the same situation as other groups that we're trying to increase the representation of.

Dr. Mari Knettle:

When we're talking about the specific accommodations that can be made for students you know, in the process that we go through to determine what those accommodations are, how does that differ when we're talking about didactic education and when we're talking about clinical education.

Rachel King:

So, the basic requirement under section 504 or under the ADA is the same. We must provide reasonable accommodation that allows, if you're talking about employees, the employees to perform the essential functions of their job. If you're talking about students, we have to provide them with reasonable accommodation, unless it's going to alter the fundamental nature of the course that we're, that they are taking. So, it's the same obligation. It's described differently if you're talking about students in didactics than if you are talking about students in clinical settings or employees in clinical settings, but it is the same obligation. The types of accommodation you're gonna provide are obviously going to be different and you're going to consider different factors if you're talking about students in an academic setting versus students in a clinical setting.

Dr. Mari Knettle:

So, are different individuals involved? I'm thinking about the role of, for example, a, an academic faculty member. They most likely are familiar with accommodations, but when we're talking about the clinical setting, I think, maybe I'm wrong, but I think that the clinical preceptor may have less of an awareness of the requirements for disability accommodations in education, who to involve in the conversation, what can happen, what can't happen. I would think that the players are different or, you know, the contributors to the conversations.

Rachel King:

I think that's right to a certain extent. I don't know that... I think there's a lack of understanding of the obligation to provide accommodation across the board. But I agree with you, particularly faculty at colleges or universities are probably much more familiar with students getting accommodation in that setting. I think what can be particularly difficult in a clinical setting is really knowing when someone's requesting accommodation. This is true, whether they're a student or they're an employee.

So if you're a preceptor and you are, you know, you're giving feedback to your student who explains that they had difficulty with this or that because they were having a vision problem or they, you know, needed to rest, or some other thing that could be connected to a disability, the preceptor may not always understand that to be a request for an accommodation. And so, it is much more likely that a preceptor is going to miss that initial signal, that they need to engage in a discussion of whether accommodations are needed than a faculty member in a traditional academic setting.

Dr. Mari Knettle:

So, what if the preceptor does pick up on that signal? They realize, you know, this student is asking me for accommodation and maybe they know that there's an obligation to provide that accommodation. Do they need to go back to the academic institute and talk about it, or do they have to respect the student's privacy and not talk about it? So, who should be involved when that happens?

Rachel King:

In a perfect universe, there's a system that they can use. So certainly, if a student is rotating from an affiliated college or university, then the college and university is going to work with them to try to figure out what accommodations are possible. Certainly, someone in a position of a preceptor shouldn't be making individual decisions about accommodating students with disabilities, because they will have many preceptors or at least several preceptors, and you want the accommodations to be consistent, you don't want them to vary across.

So as a preceptor, I would turn first to my program leadership and then probably ultimately to the school, if they are rotating from an affiliate school. And there are, there are experts. People don't always know that they're there, but finding your expert is one of the things that I would say, because someone will have a, will be able to walk you through both the process and the type of accommodations that might be necessary to provide.

Dr. Mari Knettle:

So, another kind of scenario that I think happens is when a student is considering applying to a program or they're applying, maybe have applied to a program, they will get into a conversation with a faculty member, a program director, a guidance counselor, and bring up their disability. And they're looking for advice about whether the program is a good fit for them. And I think sometimes those individuals they're talking to have perception, they make assumptions about the availability of accommodations in the clinical setting. It might be advising students away from a program on the basis of their disability thinking that's the thing to do. What can we do about that?

Rachel King:

I think one primary message is to know that every individual with a disability who needs accommodation is in a unique circumstance. So, everybody, you know, two people may share a diagnosis, but that doesn't mean it impacts them in exactly the same way. The functional limitations may be different. The place that they're going may be different. So if you have a nurse who's hard of hearing, for example, you know, there may be some contexts in which she's really going to have to listen for alerts and be unable to prof- you know, to perform in that setting, but many other ambulatory care or other situations in which it's perfectly acceptable for her to be hard of hearing, she can do, he or she can do their jobs perfectly well. So, I think it is always an individualized discussion of the person and the situation. So, you shouldn't make any assumptions about, any generalized assumptions.

One of the things that's very important when you look at accommodation is not to base your decisions on stereotypes or generalizations. And so, if someone comes, if you're a counselor or a faculty member and someone comes and presents this scenario to you, that they have a disability, and they're not sure if you don't know, don't assume. People's initial reaction is often first, we can't do that and protect patients without really defining what duties you're talking about and what ways patients might be put at risk.

And then I think people often expect a job to be performed exactly as they kind of grew up performing it. And there's all kinds of technology that assists people now that most individuals and- will not be aware of. And so, it's, it's a question of really digging down into what's required and can this person perform that and is there accommodation that's available and you're not gonna know that from the get-go. So, the first reaction should be let's- let's figure it out.

Dr. Mari Knettle:

You know, besides some of the things that you've mentioned, you know, making assumptions for one, what are some of the other pitfalls that you see with determining accommodations?

Rachel King:

So, there are process pitfalls and there are substantive pitfalls. So, under the ADA, if someone requests accommodation, you must engage in kind of a back and forth with them. It's called an interactive dialogue, in which you discuss what are the functional limitations of their disability and what reasonable accommodations are available. And I think again, because people rely on assumptions and generalizations, there's a tendency to just respond and not engage in that dialogue. So, I think that's a pitfall. One thing that is definitely true is if someone comes and requests accommodation and you're not sure if what they're proposing is going to work, you can try it for a few months. You know, an ADA accommodation process is a truly iterative process. So, you can say to them, well, I don't know if that's gonna meet either my needs as a clinician or your needs as a student, and then come back a month later, two months later, whenever it is and assess if it's working.

So, I think understanding the process is important and then substantively, you know, being creative about what solutions might be out there. And that's another reason that it's important to know who your resources are. I mean, here at the clinic, we kind of have a- a little group of people from the law department and me and HR who have seen and heard a lot of these requests and can confer about different potential solutions or different potential accommodations that we can provide. And I think it's very important to ensure that you are considering every possibility and availing yourself of every resource.

I can give an example of the- the kind of situation where assumptions might interfere. So many individuals have service animals, service dogs. And usually if a student says, for example, that they need to bring their service animal to their clinical experience, there'll be an initial fear of, you know, again, patient safety issues. What do we tell patients? What if patients are allergic, what if coworkers are allergic and just a general belief that dogs are not allowed in a hospital. And certainly, dogs are not allowed in a hospital, but in fact, if someone has a service animal, there's very few places in a hospital that their service animal cannot go, just very, just sterile environments.

And if you are a student, just like, if you are a patient or a visitor, you're entitled to have your service animal with you. And you obviously must work through all those issues, you know, is the service animal going to be there with the patients? If it- if so, how are we gonna tell patients when they make their appointments that the service animal will be there? You know, what if we have someone who's gonna, who works in the same place that has a severe allergy? Well, you know, we may need to schedule those two individuals at different times. There's, there's no question there's always something to work through, but it's also true that it can be done. And I'm not really aware of a situation where we've never been able to accommodate a service animal. And that's just kind of an example where your initial reaction might be to say no, but in fact, it's pretty, it's a relatively routine thing to accommodate a service animal.

Dr. Mari Knettle:

Speaking of resources, I think that a question that comes to mind a lot when it comes to accommodation is sometimes there's a cost associated with accommodation. How does that tie into decision making?

Rachel King:

So, there is a provision in the ADA, which says that employers don't have to provide accommodations if they are an undue burden. And that's often seen as a budget issue, but you can't just look at the budget of, you know, your program or your department, they're really gonna look at your institution. And so, it is rare that if you are a health system or a major college or university, there's going to be a budgetary reason for saying that you can't provide a certain accommodation. And it's true that, I think I saw the statistics recently, about a third of accommodations don't cost anything their changes in practices or policy, and then maybe it was 50 percent are, you know, a thousand dollars or less. So, it's not usual, you know, having to buy some complicated piece of equipment.

Dr. Mari Knettle:

Does the financial burden to provide the accommodation ever fall on the student?

Rachel King:

No. Short- short answer to that one.

Dr. Mari Knettle:

So, let's talk about how accommodations tie into student evaluation.

Rachel King:

So, they should be separate from the evaluation of the student. But you are never required to lower your standards for an individual with a disability. So thinking about a traditional, a student in a traditional academic environment, you know, their accommodation might require them to have time and a half on tests or something like that, but that doesn't mean that if you give them that accommodation, that you are required to pass them at a level that's lower than a classmate, for example. So, students must meet the requirements of their program, even if they need changes in the evaluation process.

Dr. Mari Knettle:

So that's an interesting example to say time and a half. So, one of the criteria by which students are often evaluated in the clinical setting is by their efficiency. Can they see X number of patients in a certain amount of time and do it well at a certain level? Would you call it lowering the standard if this student now is seeing patients and they're doing a wonderful job, but they're not able to see as many patients in that amount of time or perform as many procedures?

Rachel King:

You would look at what the fundamental nature of the program was. And so, my guess is for most clinical learning experiences, the goal is to have them, you know, have treated a certain number of patients or a certain type of case at a certain level. And it probably isn't to be able to do that within a particular amount of time. That may be different than when they go out in the workforce to get a job, but at a student level, if the fundamental thing is to teach them how to do X, then even if it takes them longer to do, we usually must do that. This issue comes up a lot when you have a student who, for whatever reason, can't be in clinic for, you know, the scheduled period, let's say they're supposed to come for eight-hour days, and for whatever reason, they can only come for six-hour days or four-hour days.

It is often the response of the clinic to say, well, they'll never get a job when they graduate because everybody shifts or eight-hour shifts or something. But that isn't really what the program is for. The program isn't them getting a job. The program is to teach them these skills. And if it's not going to interfere in the program for them to do it over twice as long a period, because they're coming in for four hours instead of eight hours, then we must let them do the four hours versus the eight hours. It's gonna be very fact specific again, because there'll be some programs were based on the pace of the program, they may not be able to satisfy those criteria, but things like whether they are employable in this field in the future aren't factors. It's really just, what are we trying to teach them? And can they learn it with their accommodation.

Dr. Mari Knettle:

So how can we as educators do a better job when it comes to disability accommodations and medical education? That's a big question.

Rachel King:

Well, I think, I think we've discussed a lot of aspects of that. I think just being aware that there is an accommodation process that we want to include individuals with disabilities and that we should be open and creative in our approach.

Dr. Mari Knettle:

So, when we're talking about what accommodations are acceptable, you said that we can't change the fundamental nature of the task or the activity that we're training the students to do. What's an example of something that does or doesn't change the fundamental nature of the activity?

Rachel King:

So, there's an example that we sometimes use when we think about a student who takes chemistry. So, if you are working in a chemistry lab you know, a lot of what you're doing is mixing different chemicals, pouring chemicals into different things to see their reaction or to learn to make measurements, different functions like that. And so, if you have a student who, for whatever reason is not able to physically pour or mix those chemicals, I think of- one's first reaction is to say, well, how can they possibly take this lab? All we do all day is just mix chemicals and pour them. But if you think about the purpose of the chemistry class is not to teach people to pour, it's to teach them about the chemical reactions or the chemical formulas, whatever the substance of the course is.

Rachel King:

So, if you had someone there with the student who, on the student's instructions, was doing the pouring, or maybe using the measuring devices, that student is still learning chemistry. They may not be doing the pouring, but they're learning chemistry. And so that's a situation where your initial reaction might be to say, we couldn't possibly do this because chemists poor all day long, but then if you think about it, you're not what you're really teaching them is the substance, and you could, there is a way to allow them to participate and to learn the same thing, substantively, that every other student is learning.

Dr. Mari Knettle:

Does that tie into the concept of essential functions? I know that a lot of programs will list out for the students at the outset what the essential functions of this program or this profession are. In your experience, are they doing a good job of really communicating what the essential functions are? Would that be a good guide in determining accommodation?

Rachel King:

Yes, it would if it's accurate. So often programs have what they refer to as either essential functions or technical standards. And the important thing is to ensure that those are really the technical standards, that they aren't, you're not asking students to be able to do things that really aren't fundamental to the program. So, a good set of technical standards is a great guide for people in the interactive process as to what is required of the student, but often technical standards can be over-generalizations or require things that aren't actually necessary. So, if you've got a good set of technical standards, it's very helpful, and if you've got a bad set of technical standards, it creates some compliance risk.

Dr. Mari Knettle:

What's an example of a bad technical standard?

Rachel King:

Requiring more than is really necessary. For example, if you had someone in a health profession and you require them to have perfect hearing, and it's actually a profession in which someone who is hard of hearing could be accommodated or someone who is deaf could be accommodated with a sign interpreter or some other way, that's gonna be a situation where if you have that technical standard and you stick by that technical standard, and you tell someone who's hard of hearing or deaf that they can't be accommodated, then you really are running afoul of what your obligation is.

Dr. Mari Knettle:

I know that I've seen a lot of essential functions, technical standards that say with or without accommodation.

Rachel King:

So, I find that phrase incredibly confusing, but what it really means is with accommodation. Is there accommodation we can provide that allows you to perform the essential functions of your job? Obviously, if you can perform the essential functions without any accommodation, then you're not in the ADA realm at all.

Dr. Mari Knettle:

Well, thank you so much, Rachel. This has been a great podcast. To our listeners, thank you very much, and we'll see you on our next podcast and have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.