The Accreditation Council for Graduate Medical Education (ACGME) updated the common core requirements for graduate medical education (GME) programs (effective July 1, 2019) to include a new provision, “The program, in partnership with its Sponsoring Institution, must engage in practices that focus on mission-driven, ongoing, systematic recruitment and retention of a diverse and inclusive workforce of residents.”1 The ACGME's call for greater inclusion in GME presents an opportunity to include disability as an aspect of diversity in systemic recruitment and retention efforts. A 2016 prevalence study found that 2.7% of US MD candidates disclosed disabilities, most having nonapparent disabilities (eg, attention deficit/hyperactivity disorder, learning difficulties, or psychological disabilities).2 This represents a larger cohort of students with disabilities entering GME than previously imagined3–5 and suggests potential increases in requests for accommodation. Numerous resources exist to aid undergraduate medical education programs in disability-related recruitment and retention efforts,6–13 including guidance on technical standards,14,15 clinical accommodations,16 and inclusive assessment.17,18 The GME guidance is less robust.
The GME Landscape
The ACGME advises programs that “the Sponsoring Institution must have a policy, not necessarily GME-specific, regarding accommodations for disabilities consistent with all applicable laws and regulations.”19(p14) Much existing scholarship and resources focus on resident litigation and difficulty in performance or behavior.20,21 Articles that explore successful inclusion of disabled residents espouse the value of early disclosure and use of accommodation as potential mediators of success.22,23
Residents with disabilities are already enrolled in training programs,6 and the pipeline of students in undergraduate medical education2 will soon transition to GME. To meet learner needs and realize the ACGME's new common core requirement, GME programs must create inclusive policies and practices, understand their responsibilities under federal law, and educate themselves regarding reasonable accommodations. Without those key elements, programs may be ill prepared to accommodate residents' disability-related needs (box 1). This perspective offers an overview of systemic barriers in GME for residents with disabilities and mechanisms to reframe those barriers as opportunities to build programs that are more inclusive.
Tina is enrolled in a top medical school and has performed well in medical school, due in part to having full access to the curriculum via disability accommodations. As she enters the residency match, she is concerned that her disability—dyslexia—will not be warmly received in residency and worries how she will find a program that is a good fit. Her research regarding various residency programs yields almost no information about how, when, or to whom she should request accommodations.
Tina matches into a program and is advised before graduating to disclose her disability to her program director, provide documentation, and request accommodations. As Tina is anxious about disclosing the details of her disability to the person who will evaluate her performance, and thus her career trajectory, she decides not to disclose.
In her intern year, Tina struggles. She forgoes social and other activities to stay on track. In the absence of assistive technology, Tina spends nights and weekends completing patient charts. Sleep-deprived and with a diminished social support network, Tina barely meets her first-year milestones and begins to resent the program for not providing a confidential way to disclose her disability.
In her second year, Tina is put on probation for poor performance and discloses her disability. The program director is disappointed that Tina did not ask for accommodations earlier. The emotional toll of trying to keep up results in Tina taking a 6-month leave of absence, with potential financial and career consequences. When Tina returns to the program, she requests and is approved for accommodations.
Systemic Barriers in GME
The scenario described in the box 1 is not unique. A 2018 report from the Association of American Medical Colleges identified 3 structural barriers to accessibility in GME, which included the absence of clearly defined policies and processes, a knowledgeable and identifiable point person for facilitating accessibility requests, and an understanding of the legal requirements for equal access under the Americans with Disabilities Act as amended (ADA-AA).24 To those 3 barriers, we add a fourth: unfamiliarity with the benefits of disability inclusion.
Poorly Defined Policies and Processes
Residents exist in a liminal space between student and employee, resulting in some confusion about who oversees disability-related needs. When programs fail to identify policies for requesting disability accommodations, residents lack clarity about who is responsible, or they incorrectly assume that the program does not make accommodations. The lack of explicit accommodation policies may also discourage qualified applicants.
Absence of a Knowledgeable and Identifiable Point Person
The lack of a qualified expert in disability inclusion as part of the interactive process to determine accommodations also poses a barrier. Legal requirements call for such a process, necessitating a good-faith exploration of options between the resident and the institution.
Insufficient Understanding of Program Requirements Under the ADA-AA
Program leadership may not have a clear understanding of institutional obligations under employment provisions of the ADA-AA (Title I). The law outlines employer obligations to ensure equal access for qualified employees with disabilities, including provision of reasonable accommodations and responsibility to fund them.25
Lack of Knowledge Regarding the Benefits of Disability Inclusion
Program directors may not fully appreciate the benefits of disability inclusion and may falsely believe that residents with disabilities require dedicated administrative time or add high costs to the program.
Mechanisms for Full Inclusion
Increase Transparency in Policies and Process
Straightforward accommodation policies and statements that emphasize the value of disability as part of diversity help to destigmatize disability. These measures also aid in recruitment and retention of diverse applicants (table; box 2). Programs should provide accommodation policies in communications to prospective and matched residents, on program websites, and in resident handbooks. Programs and institutions must also develop their understanding of financial responsibilities for employee accommodations. Transparency about the accommodation process will likely facilitate earlier disclosure by residents, a potential mediator of success, regardless of whether the resident enters the program with a disability or develops one during training.22
Dan is excited to enter residency. He is very open about his disability, a chronic health condition, and had a great undergraduate medical education experience. He purposely reviewed the websites of all programs of interest, looking for information about disability and accommodations.
One program had a clear and confidential process for requesting accommodations, and the website contained a welcoming statement, “[The program] has proudly trained and currently employs physicians with disabilities.” Dan followed the process, which included a confidential interview with human resources, before entering into a collaborative discussion with the program directors. Human resources staff was knowledgeable about accommodations and worked with the program to quickly approve and implement Dan's requests. Dan felt respected and protected as his documentation of disability remained with the human resources office.
Dan thrived in residency, connecting well with patients and colleagues. He utilized his accommodations, including assistive technology (which was ordered and paid for by human resources) and release from clinic twice a month for infusions. He went on to match in a highly competitive fellowship.
Include a Confidential and Specialized Disability Expert in the Process
Programs should work with GME offices to establish a process for disability disclosure that includes a confidential point of contact with expert knowledge of disability law and clinical accommodations (figure) who can assist with determining reasonable accommodations (box 3).6 This should be someone other than a colleague, supervisor, or anyone else who would evaluate the resident's performance.
In medical school, Maria successfully worked with real-time captioning in lecture settings and was able to communicate well with small ward teams in slower-paced clinic and hospital settings. She matched with a residency program in a larger hospital.
During internship, she found it difficult to follow the rapid pace of discussions amid increased noise on the wards, and noon education sessions were also harder to follow. She met with her program director to discuss these concerns and the potential need for accommodations. Maria and her program director were uncertain about what would work and were concerned about cost. They contacted her institution's disability expert, who met with each.
After exploring multiple options offered by the disability expert, Maria and her program director determined that a small wireless microphone and an oral interpreter were most effective. Given the centralized budgeting of accommodations for this institution, the program director did not need to order equipment or hire the oral interpreter; the equipment was facilitated by the disability office, and the oral interpreter was scheduled in consultation with the program coordinator. In her second year, Maria was an effective and highly valued resident.
Understand Program and Institutional Obligations
Programs should maintain a clear understanding of their legal responsibilities, including those for reasonable accommodations. The ADA-AA defines disability broadly; thus, programs should anticipate implementing accommodations for residents with all categories of disabilities. Examples of reasonable accommodations include sign language interpreters, modified work schedules, and protected time for health-related appointments.25 While accommodations that pose undue administrative or financial hardship are not required, case law26 clarifies that the overall financial resources of the institution determine hardship. Most accommodations are not prohibitive: one study27 showed that approximately 33% of accommodations had zero cost while 50% were less than $5,000 across the entire period of residency. To date, no studies, to our knowledge, have addressed time and administrative costs of residents with disabilities. However, program directors regularly allot time to all residents for performance review, career guidance, and personal mentoring, and they meet with residents when remediation or disciplinary action is required. The proactive development of an inclusive training environment and clear policies may reduce administrative time and academic distress caused by a failure to accommodate. Furthermore, although rare, litigation may result in significant time and resource costs when the rights of learners with disabilities have not been appropriately addressed.
Enhance Knowledge of the Benefits of Inclusion to Patients and Residents
Programs should seek to understand the benefits of disability inclusion. Physicians with disabilities inform health care practices for patients with disabilities and may reduce disparate population health outcomes.28–30 Physicians and learners have suggested their lived experiences with disability lead to greater empathy for patients and enrich the educational learning environment.6,10 Research shows that physicians with disabilities are more likely to provide care for underserved and disability-concordant populations.31 Furthermore, investing in disability-related inclusion has the potential to improve conditions for all residents, regardless of disability status.22
Residency programs should prepare for an increasing number of residents with disabilities who have accessed undergraduate medical education accommodations, are knowledgeable about the law, and may request GME accommodations. In line with ACGME's focus on the inclusion of a more diverse resident population, programs should seek to develop transparent processes, identify a knowledgeable disability expert, solidify their understanding of the ADA-AA, and understand the benefits of inclusion to patients and residents. Ensuring that programs are accessible to residents with disabilities is imperative to maintaining the pipeline of physicians with disabilities, from premedical education to practice. By improving the climate for residents with disabilities, GME programs can successfully realize the promise of diversity among physicians with disabilities.