Lauren Vogel | CMAJ | May 3, 2018
Clunky bureaucracy and inconsistent policies often cause unnecessary stress and delays in medical training for people with disabilities.
Dr. Vera Krejcik was looking forward to starting residency when a stroke left her with hemiparesis, or weakness in one side of her body. Suddenly, continuing in internal medicine wasn’t possible, and the path to resuming her training was uncharted. “It was very difficult but, with creativity, I was able to transition into psychiatry and have a great career,” says Krejcik, the president of the Canadian Association of Physicians with Disabilities.
Every step along the way was a first for her residency program. “I asked had anyone gone through with a similar disability, and they couldn’t provide details,” she explains. It took months to get one-off accommodations in place. It’s a common and frustrating experience for many trainees with disabilities, Krejcik says. “We’re still very much in a place where it’s case by case.”
According to a recent report by the Association of American Medical Colleges, the structures and culture of medical education are set against trainees with disabilities. The report describes a lack of accessibility policies and processes, irrelevant or nonexistent technical standards, disability service providers who know nothing about the realities of medical training, and a lack of information and meaningful accommodations for trainees. Stigma and stereotypes abound. In some cases, trainees with disabilities are “counseled out of specialties.”
The same is true in Canada, says Dr. Franco Rizzuti, past-president of the Canadian Federation of Medical Students. It’s never overt, but there is an undertone that “you can’t be in medicine unless you’re in perfect health.”
Rizzuti took six months off medical school after an accident, spending half that time figuring out accommodations. His school had no problem granting a short-term leave, but things became more complicated once it became clear his disability would persist.
Technical standards for medical education are vague and very high-level, resulting in “considerable variability” in accommodations, Rizzuti explains. “There isn’t a job description of what a medical student does throughout the day and the things you need to be able to do.”
According to Krejcik, there are also “tremendous gaps” in accommodation policies and processes. Some schools rely on a university’s general accessibility services, but often these provide only basic supports like extra exam time or audio-visual aids. They’re less helpful when a trainee needs to demonstrate clinical skills, such as suturing.
“Other schools have very little in the way of accommodations,” Krejcik says. Trainees with disabilities often have to negotiate supports as one-off exceptions. Even when there are processes for disclosing a disability, “there’s a lack of information” about when and how to do it and what sort of accommodation is possible.
Trainees often have to extend their education to work around these gaps, sometimes at a cost to their careers. “If you’re extending time for your program, that puts you off cycle for your residency match and your licensing exams and there might be extra costs of living,” Rizzuti says. “There isn’t the ability to hit pause and quickly pick up where you left off.”
The residency match is particularly fraught because the accommodations available at one institution may not be possible at another, he adds. Those who disclose disabilities also run the risk of discrimination in the match.
Because of these barriers, some trainees ignore or hide disabilities as long as possible. “Learners don’t necessarily feel safe in disclosing the need for accommodation,” explains Krejcik. “Even though my disability is more obvious, it was a hurdle, mentally, to ask for what I needed.”
According to Dr. Kimberly Williams, past-president of Resident Doctors of Canada, these problems also rob medicine of much needed diversity. “That’s how we grow as a profession, because with diversity comes new thoughts and change and innovation.”
Williams chairs a working group on accommodations for trainees with disabilities as part of a new post-graduate medical education governance council comprisng representatives from resident organizations, faculties of medicine and medical regulators. The working group is looking at “high-level principles” for standardizing accommodation policies and processes in residency programs across the country.
“The other thing that would be nice, from a resident perspective, would be having an external ombudsman” to help trainees navigate accommodation processes, she said.
Krejcik, who also sits on the working group, hopes to see the development of “some de-identified or anonymized process to share accommodations and policies between the schools.” This would prevent students with similar disabilities from having to “reinvent the wheel at each step,” she said.
At the undergraduate level, Rizzuti says, “there really isn’t the same concerted effort.” However, “the Canadian Federation of Medical Students has started to incorporate this into our wellness programming.”
Photo credit: vadimguzhva/iStock
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