When Dr. Bliss Temple was in training, she remembers being in an elevator wearing her white coat and her stethoscope when a patient who was using a wheelchair got in. Temple is paraplegic; she also uses a wheelchair.
“We checked out each other’s chairs, and then he looked at me and said, ‘Oh! You’ve joined the enemy.’ ”
More than 56 million Americans have a disability of some kind—nearly a fifth of the country. Yet a vanishingly small percentage of doctors have a disability of any kind—estimates vary and data is scant, but the consensus suggests that the number is somewhere around 1 percent. The problem starts at the tip of the pipeline: People with disabilities make up somewhere between 0.3 and 2.7 percent of medical school classes—estimates vary, but even at the high end, this makes them one of the most underrepresented groups in American higher education.
The divide is stark, and the consequences can be severe. Americans with disabilities are more likely to be sick but less likely to get adequate health care. This is partially because having a disability increases the likelihood of being poor or being unable to access care. But it has also created a system in which vulnerable patients feel their doctors misunderstand their bodies and their lives.
Colleagues sometimes tell Temple that they don’t think of her as a person with a disability, even though she’s spent her career at San Francisco General Hospital working on health care access and social justice for people with disabilities, including stints at the World Health Organization and consulting for the Department of Health and Human Services.She’s no stranger to the stereotype that doctors don’t have disabilities. Doctors take care of us in our most critical moments, when their ability to do their jobs can make a mortal difference. We want doctors who look like they can rush us to the intensive care unit like it’s 45 minutes through an episode of a medical drama.
But in recent years, disability activists and policy experts have argued—persuasively, according to many court cases—that disability does not prevent medical students from learning how to provide excellent medical care, particularly when they can receive assistance from increasingly adept technical tools. Not only is denying their right to train as doctors illegal; it inadvertently denies the many Americans with disabilities the benefit of having more medical professionals who understand them.
Additional Resources for Technical Standards and Accommodations
The struggle for representation in medicine starts with who gets to go to medical school in the first place. For most aspiring doctors, medical school admission is merely a matter of excelling at coursework, research, volunteering, the Medical College Admission Test, personal essays, and interviews. Even then it’s tough going—most medical schools have admission rates in the low single digits. But students with disabilities have an additional obstacle after they’ve been admitted: They must prove to the school’s administrators that they can meet the physical requirements of medical education. These expectations, codified into “technical standards,” are often broken down into five essential functions: observation, communication, motor function, conceptual and quantitative analysis, and socialskills. The exact standards vary by school and curriculum. For example, MD candidates at one school may have to personally deliver 10 babies to pass an obstetrics rotation while candidates at another only have to assist. This idiosyncrasy wouldn’t matter to most applicants, but it can disqualify someone with limited arm mobility, no matter how dazzling their application. After getting in on the strength of their grades, scores, and essays, students can find themselves caught between forfeiting their admission and signing a document pledging they can perform medical procedures with accommodations that they don’t know for sure that they’ll receive.
For years, medical schools have defended their technical standards by arguing that they protect patient safety and ensure academic consistency. Reformers argue that these policies violate federal law and promote a culture of prejudice. In 1973, the Rehabilitation Act prohibited universities, and other institutions receiving federal funding, from discriminating against applicants with disabilities who were “otherwise qualified.” But the law’s vague language left it open to evasion. In 1990, the Americans With Disabilities Act, or ADA, reinforced and expanded the scope of the Rehabilitation Act, affirming that in higher education and employment, people with disabilities could not be “excluded, denied services, segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids and services,” unless the university can show that accommodations would “fundamentally alter” the education they offer or result in “an undue burden.”
Perhaps unsurprisingly, this federal law compelled only a modest increase in the number of students with disabilities graduating from medical school. In 1979, six years after the Rehabilitation Act’s passage, the Association of American Medical Colleges, or AAMC, published a technical standards template to guide medical schools as they began to read applications they could have quickly rejected a few years earlier. After the ADA was passed, many medical schools complied with the law by simply copying the AAMC’s 1979 guide near-verbatim and haven’t changed them much since. At the time, the AAMC seemed more concerned about preventing lawsuits than inclusion. “In the admissions process, the burden of proof is on the applicant to demonstrate that he/she can meet the essential 5 functions of the program,” an AAMC memo from 1993 read. “How much accommodation may be too much is a matter which will be tested in the courts. The safety of patients involved in student education is of paramount importance.” To this day, many schools leave the burden on aspiring physicians with disabilities.