Graduate medical education (GME) institutions must ensure equal access for trainees with disabilities through appropriate and reasonable accommodations and policies. To date, no comprehensive review of the availability and inclusiveness of GME policies for residents with disabilities exists.
We examined institutions' compliance with Accreditation Council for Graduate Medical Education (ACGME) requirements and alignment with Association of American Medical Colleges (AAMC) policy considerations.
Between June and August 2019, we conducted a directed content analysis of GME institutional policies using the AAMC report on disability considerations and the ACGME institutional requirements as a framework.
Of the 47 GME handbooks available for review, 32 (68%) included a disability policy. Forty-one of the 47 (87%) handbooks maintained a nondiscrimination statement that included disability. Twelve of the 32 (38%) handbooks included a specific disability policy and language that encouraged disclosure, and 17 (53%) included a statement about the confidential documentation used to determine reasonable accommodations. Nineteen of the 32 (59%) maintained a clear procedure for disclosing disabilities and requesting accommodations.
While disability policies are present in many of the largest GME institutions, it is not yet a standardized practice. For institutions maintaining a disability policy, many lack key elements identified as best practices in the AAMC considerations.
The role of graduate medical education (GME) in training resident physicians with disabilities has garnered new attention. This is in part due to a new emphasis on the purposeful recruiting and retention of diverse populations, including abilities, from the Accreditation Council for Graduate Medical Education (ACGME). In 2019 and 2020, the ACGME implemented new institutional and program requirements on disability policies and accommodating residents.1,2 The aforementioned changes to the ACGME, coupled with an increase in the number of medical students disclosing disabilities,3 foreshadows an increase in the number of residents with disabilities, which has implications for institutions and learners.
Institutions can realize the diversity goals of the ACGME and the inclusion of trainees with disabilities through appropriate and reasonable accommodations.4,5 A recent Association of American Medical Colleges (AAMC) report on disability inclusion6 and new ACGME requirements1 offer guidance to institutions regarding the inclusion of trainees with disabilities (box 1). Failure to align with these guidelines may result in adverse implications for institutions and learners,4–6 leaving both ill-prepared to navigate accommodation requests. Specifically, institutions without a disability policy will violate ACGME requirements. Lack of policy may also disincentivize disability disclosure6 or stymie the process for learners, resulting in late disclosure of disability and potential underperformance.7
Maintain a policy “regarding accommodations for disabilities consistent with all applicable laws and regulations”.
Programs must provide, as part of their resources, “accommodations for residents with disabilities consistent with the Sponsoring Institution's policy”.
Make a statement about valuing diversity (including disability) in the residency program to reduce the stigma around disclosing disability.
Include a clear statement about how to request accommodations in invitations for interviews, including a specific contact person. State what measures you have already taken to ensure access for interviewees (eg, all interview spaces are wheelchair accessible).
Ensure that diversity initiatives explicitly include disability as an aspect of diversity valued in institutions.
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; AAMC, Association of American Medical Colleges.
Currently, there is no information on whether GME institutional policies align with ACGME requirements and AAMC considerations. To determine alignment, we reviewed disability policies at the 50 largest GME sponsoring institutions to understand compliance with ACGME requirements to maintain an institutional disability policy and alignment with AAMC considerations for inclusive elements within disability policies.
We requested and received data on GME institutional size from the ACGME. We elected to analyze the 50 largest institutions in the United States, representing 25% of all trainees. Between June and August 2019, we conducted a search of institutional websites to obtain GME handbooks. If handbooks were unavailable online, we requested a copy by emailing the designated institutional official and/or GME director. Up to 3 email reminders were sent at 1-week intervals. To explore whether institutional policies on disability complied with the ACGME requirements and aligned with the AAMC considerations, we conducted a directed qualitative content analysis, where data are reviewed for content and coded for exemplification of the identified categories.8,9 Policies and elements of policy were coded using ACGME requirements and AAMC considerations as a framework for creating categories (box 2). Additionally, we collected information on the presence of a nondiscrimination statement within the policy and whether policies were publicly available. Two authors (B.C. and C.C.) independently coded all 50 policies. Disagreements were resolved by the lead author (L.M.).
Defined as a policy that directs residents with disabilities to the process for (A) disclosing a disability and (B) requesting accommodations. Coded as 0 for no policy, 1 for disclosure and/or request for accommodation, and 99 for unavailable if a policy was not made available online or from the school.
Defined as the availability of GME or house staff manual on the institution's website under the GME office web page. Coded as 0 for unavailable (this includes having policy manuals behind a firewall), 1 for publicly available.
No was coded 0 and defined as indicating the lack of information beyond an initial contact person and yes was coded with a 1 and indicates that detailed information was provided above and beyond the initial contact person information (eg, process for disclosure, links to forms, listing of decision-making process). Coded as 99 for unavailable if a policy was not made available online or from the school.
Coded as no (0) or yes (1). Yes indicated that there is a statement about the confidential nature of the documents and information used to determine reasonable accommodations. No indicated that there is no statement regarding confidentiality. Coded as 99 for unavailable if a policy was not made available online or from the school.
Coded as no (0) or yes (1). Yes indicated any language that encouraged disclosure or spoke to the value of disability in GME. Examples included “We encourage residents/house staff to disclose and request accommodations” and “We value diversity, including residents/house staff with disabilities.” No indicated that only legal language was used. Examples of encouraging language were cut and pasted into the code book, if applicable. Coded as 99 for unavailable if a policy was not made available online or from the school.
Coded as 1 of 6 options: (1) program director, (2) designated institutional officer, (3) human resources, (4) occupational health, (5) multiple parties, (6) other, and (99) policy unavailable.
Defined as a statement in the GME policy manual or ancillary policy that affirms the institution's commitment to nondiscrimination of individuals with disabilities. Coded as 0 for no statement and 1 for statement of nondiscrimination.
Abbreviations: GME, graduate medical education; ACGME, Accreditation Council for Graduate Medical Education; AAMC, Association of American Medical Colleges.
The University of Michigan Institutional Review Board exempted this study.
Availability of GME Handbooks
Of the 50 GME institutions reviewed, 38 (76%) maintained publicly available GME handbooks. Nine of the 12 institutions without online handbooks provided them via email; 3 were nonresponsive. Overall, handbooks from 47 of 50 (94%) institutions were reviewed and coded.
Compliance With ACGME Requirements to Maintain a Disability Policy
Of the 47 GME handbooks reviewed, 32 (68%) complied with ACGME requirements to maintain a disability policy, and 41 (87%) maintained a GME statement of nondiscrimination including disability. Disability policies were publicly available at 23 of the 47 institutions (49%).
Alignment of Disability Policies With AAMC Considerations
Encouraging Language, Statement of Confidentiality, and Clear Procedures
Of the 32 programs with a disability policy, 12 (38%) included language that encouraged disclosure and spoke to the value of disability in GME; 17 (53%) included a statement about the confidential nature of the documentation used to determine reasonable accommodations. Nineteen of the 32 (59%) maintained a clear procedure for disclosing disabilities and requesting accommodations.
Initial Point Person for Disclosure of Disability
Of the 32 institutions that maintained disability policies, the majority were in direct opposition to the AAMC considerations. When added together, over half of the reporting structures required residents to disclose a disability to the program directors (28%, 9 of 32) or multiple parties, such as program directors and human resources (25%, 8 of 32). Four institutions (13%) provided no information about how to disclose or to whom. Only 5 programs reported a disclosure structure in line with AAMC considerations (see box 2), including the disability office (9%), human resources (6%), and occupational health (1%).
A majority of institutions (68%, 32 of 47) complied with the ACGME's requirement to maintain a disability policy; however, most policies did not fully align with the AAMC considerations. Less than half of the disability-specific policies were publicly available.
Failure to maintain a disability policy in line with ACGME requirements and AAMC considerations has multiple consequences. First, in the absence of publicly available policies, applicants with disabilities may not apply to a specific program, believing it is not inclusive of people with disabilities. The lack of language that encourages disclosure and speaks to the value of disability in GME may also dissuade learners with disabilities from applying to an institution. Consequently, institutions may lose valuable opportunities to meet the ACGME's goal of recruiting and retaining a diverse cohort of underrepresented trainees through the inclusion of residents with disabilities. Finally, the absence of specific instructions on how to disclose disability delays or disincentivizes trainees with disabilities who wish to disclose disability and request accommodations. This may result in failure to request accommodation and late disclosure of disability to the program only after a resident begins to struggle. Trainees with disabilities who forgo accommodations may be at higher risk for underperforming.6,7 Finally, more than half of the programs required disclosure to a direct supervisor who maintains an element of control over a trainee's career trajectory, a known disincentive to disclosure.6,10
Our findings raise concerns about GME institutions' compliance with the ACGME requirements1 and have implications for diversity and inclusion in GME. By creating inclusive policies and broadcasting a commitment to disability as a form of diversity, GME can improve recruitment and retention of residents with disabilities, helping to realize the ACGME's goals for a more diverse health care workforce.
This study has limitations. Some GME programs did not maintain publicly available handbooks, and 3 programs did not respond to our requests. Policy review is limited to evaluating an outward-facing shell and may not accurately represent the institutional culture. The decision to select the largest GME program limits the generalizability of our findings to smaller, community-based, and non–university-affiliated training sites. Absence of policy represents only one barrier to disclosure. Residents may not disclose disability due to reporting requirements for state licensing boards11–13 or because of concerns that supervisors will question their ability to perform job duties.6,14–16 Therefore, failure to disclose may not be ameliorated by changes in policy.
Future studies should address these concerns, including whether the alignment of policies with recommendations is predictive of the actual inclusive culture of an institution and whether these policies impact applicant interest, ranking, and matching at institutions. Finally, research is needed to identify the barriers to licensure and certification pathways for physicians with disabilities.
While disability policies are present in many of the largest ACGME-accredited institutions, it is not yet a standardized practice. For institutions that maintain a disability policy, most lack the pillars of an inclusive foundation as outlined in the considerations from the AAMC and therefore fall short of achieving a full commitment to diversity. Inclusive policies with institution-wide messaging that communicates a commitment to disability inclusion is needed to cultivate an environment where disability disclosure is a normalized and protected process.16–21
Funding: The authors report no external funding source for this study.
Conflict of interest: The authors declare they have no competing interests.