The Braille Monitor                                                                                               January, 2004

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Barriers Fall for Disabled Medical Students

by Linda Villarosa

From the Editor: The following article appeared in the November 25, 2003, edition of the New York Times. It provides a useful summary of the situation facing disabled people today who want to enter medicine. This is what it says:

As a fourth year medical student, Jeffrey Lawler listens—really listens—as his patients run through their lists of physical complaints. When he touches a scar or feels for bumps, lumps, or growths, he directs all of his focus into his hands, moving his fingertips slowly over skin, tissue, and bone, occasionally pressing and prodding gently. A talking blood pressure cuff recites readings in an automated voice, and a nurse or fellow medical student lets Mr. Lawler know that a patient's temperature is hovering around 100.

Mr. Lawler's hearing and sense of touch are extra finely tuned, because he cannot look into a patient's eyes or see if a wound has healed. He cannot read the numbers on a thermometer, blood pressure monitor, or his pager.

His eyesight began fading twenty years ago, as a result of the disease retinitis pigmentosa. By 1993 Mr. Lawler, now forty-three, was legally blind. Still he took the medical college application test with the help of a reader and a scribe and was accepted to Western University Medical School in Pomona, California. He will graduate in June near the top of his class and hopes to practice physical medicine and rehabilitation.

"The human body fascinates me, but my greatest strength as a doctor is patient contact," said Mr. Lawler, who is rarely without his guide dog Burke. "Yes, my knowledge is good, but I also bring empathy to the bedside. I've been treated by doctors who didn't really listen to me or said things like, `You're not planning on having children, are you?' So I take my time with patients and try to really listen and thoroughly explain things."

In the past, students with physical disabilities were rarely accepted to medical school, and they rarely completed it. But now Mr. Lawler joins a growing number of students with disabilities who are thriving in medical school. Though no statistics document how many of these students are attending medical school or how many disabled doctors are practicing, experts in the field note that laws like the Americans with Disabilities Act of 1990 allowed disabled students access to every level of education and helped propel the current increase in medical students.

"Over the past several decades, the doors have opened for kids with disabilities to go to school, get diplomas, and graduate, so we've seen huge increases in the numbers of disabled students in undergrad," said Martha Smith, project coordinator of the Center on Self Determination of Oregon Health and Science University. A survey of the American Council on Education notes that the number of full time freshmen with disabilities has increased to 11 percent from 7 percent from 1988 to 1999.

"As a result," Ms. Smith said, "these college students with disabilities are part of the next wave of students who say, `I can go on to professional schools.' Over the past several years, faculty members and administrators in health sciences programs have noted that they are experiencing an increase in the number of students with disabilities who are both applying and getting in medical and dental schools and nursing programs."

Ms. Smith and colleagues at the Center on Self Determination have trained faculty and staff members at about twenty-five medical schools in the last three years, focusing on ways to accommodate the students without sacrificing medical standards and patient safety.

Brenda Premo, director of the four-year-old Center for Disability Issues and the Health Professions at Western University, said: "When I first came here, the idea of a deaf or blind person being in medical school was so foreign that no one knew what I was talking about. Now I'm getting several calls a month from students with disabilities saying they want to go into health professions and many who want to become doctors."

Dr. Lisa I. Iezzoni says times have changed, perhaps drastically, from the early 80's when she attended Harvard Medical School. In her new book, When Walking Fails: Mobility Problems of Adults With Chronic Conditions, she writes poignantly of her battle with multiple sclerosis, which struck her just as she began medical school.

After graduating in 1984, Dr. Iezzoni, now a professor of medicine at Harvard, decided against practicing and chose research, partly because of an internship adviser who suggested that he could pass a "hat around to the chiefs of medicine at the various Harvard hospitals to see what they would donate toward a salary for my internship."

"A top leader at a Harvard teaching hospital also told me that there were too many doctors in the country right now for us to worry about training a handicapped doctor," said Dr. Iezzoni, forty-nine, who uses a motorized scooter. "I do regret not becoming a physician, but at some point I realized that I would be fighting all the way, at the same time I was fighting my body."

Despite increased acceptance of people with disabilities and changes in laws, attitudes may still be hard to sway, particularly in medicine.

"Doctors are the least comfortable and often the least knowledgeable about disability issues," said Dr. Julie Madorsky, fifty-eight, who practiced from 1969 to 1995. She had childhood polio and was the prototype for the character Dr. Kerry Weaver, the attending physician who walks with the aid of a crutch on the television series "ER"

Dr. Madorsky said: "There's a concept that it's `them' and `us.' The idea that someone can enter medicine with a physical disability is counterintuitive. It goes against the notion that doctors are healthy and perfect and able bodied and patients are not."

Some people in the field worry that the physically disabled cannot fulfill the clinical requirements of medical school and that they need special treatment to graduate. There is no national criterion for technical standards for admission and graduation, and each of the nation's 126 medical schools is responsible for creating and publishing its own graduation requirements.

"It's very tricky," said Dr. Robert Sabalis, associate vice president of student affairs and programs at the Association of American Medical Colleges in Washington. The organization soon plans to produce an updated overview of legal requirements for disabled medical students.

"Some medical schools, for example, say that one cannot rely on the physical skills of a third party for assistance, but other schools don't have that," Dr. Sabalis said.

Advocates for disabled students argue that some medical school standards that create hurdles for the disabled are outmoded.

"Too many schools are using the standard that a doctor has to see perfectly, walk perfectly, and hear perfectly, but if they really followed that standard, no one would graduate," said Ms. Premo of the Center for Disability Issues.

"I support dropping students who don't achieve, and I don't believe in lowering standards," she added, "but you have to allow for difference."

The disabilities legislation may have had other influences as well. No studies have looked at malpractice and whether disabled doctors and medical students are at higher risk. But, according to the Physician Insurers Association of America, a trade association of medical malpractice insurance companies, there is no difference in underwriting medical liability policies for doctors who are disabled and those who are not.

"Our application and underwriting process is blind to disabilities," said Frank O'Neil, a senior vice president at the ProAssurance Corporation, one of the nation's largest medical liability insurance companies. "As long as a doctor is trained and able to perform the procedures for which they are applying for coverage—with or without an accommodation, like a physician extender—we don't care."

Mr. Lawler, the student, said he had a hard time getting a surgery rotation, a medical school requirement, because of his blindness.

"Me being in the operating room became a big issue," he said. "In the third year you don't do anything except hold retractors during surgery, but it was very challenging finding a site where I'd be accepted. Finally I was able to scrub in on a procedure, and I was extremely focused. All I did was hold the retractor like old medical students do to keep the cavity open, but I really concentrated because I knew I was under a microscope and didn't want to screw up."

Mr. Lawler said he trained with a physician who was also blind, Dr. Stanley Yarnell, who practiced rehabilitation medicine in the San Francisco area for twenty-seven years before retiring in June. Dr. Yarnell, fifty-five, who began losing his vision in 1969 because of recurrent optic neuritis, said he considered medicine to be a cognitive process.

"When I couldn't see something, I was able to get what I needed in terms of a description from a resident, nurse, or even a patient," Dr. Yarnell said. "But there are other low tech ways to practice without vision. I can get a fair idea of what a patient's limp is like by walking with someone with my hands on their back, shoulders, and hips. That doesn't require vision."

As for insurance coverage, Dr. Yarnell said, "The company knew I was blind, but as long as I could perform a procedure safely with or without accommodation, then the malpractice carrier had to insure me at the same rate as other physicians performing the same procedures."

Dr. Margaret Stineman, an associate professor of rehabilitation medicine at the University of Pennsylvania, was born with a deformity of her skeletal system, a reduced lung capacity, and missing muscles to move her eyes. She consults on rehabilitation of patients with neurological injuries.

"I look for settings where my mind and creativity are valued because these are the two particular gifts I have," Dr. Stineman said.

She said that early in her career some mentors were concerned that she might have difficulty getting through medical school. To her knowledge, however, "there has never been a patient who has been uncomfortable with my disabilities," she said. "I work in a trauma service, and as a person who has lived with disabilities, I can help my patients figure out how to develop ways to overcome their physical problems and grow. The life experiences that I've had are part of what I bring to patients, and they appreciate that."

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