Realizing a Diverse and Inclusive Workforce: Equal Access for Residents With Disabilities

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 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, 23Residents 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. 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. 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. 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. 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. 25Program 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. 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. 22Programs 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. 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. 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. 22Residency 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.