Disability as Diversity: A Case Studies Companion Guide

By Leslie Neal-Boylan

Administrators in medical, nursing and health science programs are witnessing a substantial increase in the number of students with disabilities  entering their programs. Concurrently, the benefits of diversity in healthcare are becoming increasingly apparent and important. A commitment to disability inclusion for qualified students should be a high-level goal of nursing, medical, and other health science programs. To support this goal, leaders in these areas must develop robust programs and an understanding of the needs of qualified students with disabilities in the health sciences and accompanying best practices for inclusion. This book of case studies is the perfect companion to Meeks' and Neal-Boylan's recently-published book Disability as Diversity. It contains ten cases related to medicine and nursing but with significant relevance to other health professions.  Each case is preceded by an introduction with instructions onhow  to use it. The cases are followed by discussion questions and perspectives from the student, faculty and disability resource professional viewpoints. The cases are then deconstructed with reference to the book Disability as Diversity, relevant citations from the literature and case law. Developed by some of the most notable researchers and clinicians in the field this case book serves as truly invaluable resource for deans, program directors, faculty and student affairs personnel. Offices can use these cases as a platform for critical discussion and training about disability processes, policies and decision-making regarding accommodations and inclusion.

• Language: English
• Publisher: Springer
• Release date: Oct 31, 2020
• ISBN: 9783030558864

Book preview

Part IMedical Student Cases

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

L. Neal-Boylan, L. M. Meeks (eds.)Disability as Diversityhttps://doi.org/10.1007/978-3-030-55886-4_1

1. The Student with a Learning Disability: Clarissa Connors, a Medical Student with Undiagnosed ADHD and a Learning Disability

Kristina H. Petersen¹  , Stacy C. Jones²   and Lisa M. Meeks³  

(1)

New York Medical College, Valhalla, NY, USA

(2)

Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA

(3)

Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA

Kristina H. Petersen (Corresponding author)

Email: [e-mail]

Stacy C. Jones

Email: [e-mail]

Lisa M. Meeks

Email: [e-mail]

Keywords

ADHDClinical accommodationsDidactic accommodationsExamination accommodationsProcessing disabilityReading disabilitySocioeconomic barriers

Case History

From the first day of medical school orientation, Clarissa felt out of place. While most of her medical student peers were from affluent backgrounds, Clarissa came from a low-income family and was still struggling financially. She majored in Spanish and American Sign Language, while most of her peers were science majors, and some had graduate degrees.

Clarissa’s sense of "otherness¹" intensified on the first day of classes, when she found herself unable to keep up with and comprehend lecture content. She left after the first four hours of class, opting instead to study on her own and watch lecture recordings at her own pace . Clarissa quickly became frustrated at her inability to finish the daily readings for each course. She could only get through a few pages and retained very little. Clarissa encountered further barriers in small group sessions, in part because she had not completed the assigned readings. She also had difficulty following the group’s conversations and often felt lost. Feeling ashamed and frustrated, she participated even less, was often close to tears, and avoided professors, small group leaders, and advisors for fear they would think she was lazy.

Despite these struggles, when items were assigned the night before, Clarissa often felt able to prepare and thus participate . When this occurred, small group leaders noted that Clarissa seemed to have a decent grasp of knowledge and was good at seeing the big picture. In fact, Clarissa was often able to identify gaps in colleagues’ reasoning.

Despite Clarissa’s struggles, family history of learning disabilities, and ADHD, Clarissa failed to recognize herself as a person with a disability. She was not even aware of the option to apply for accommodations.

For many years, Clarissa had developed approaches to her academics that allowed her to naturally compensate for her undiagnosed disabilities. For example, during high school and college, she’d been academically successful and kept up with her peers by taking summer courses to ease her course load and worked directly with instructors to modify assignments as needed. When she began to struggle in medical school, her academic advisor suggested the barriers she was encountering were consistent with individuals who had learning disabilities, and recommended she consider being evaluated. Although the advisor mentioned she may be able to get accommodations like extra time on exams, Clarissa was very hesitant. In addition to the fear of being stigmatized, she did not feel that applying for accommodations was an option because she had never been diagnosed with a disability. She also knew that she would not be able to afford the neuropsychological evaluation, a $5000 expense not covered by her insurance. Clarissa experienced considerable anxiety over her struggle to keep up with coursework, her inability to request accommodations in the absence of documentation , and the financial burden she would face if she got formally evaluated. She felt increasingly isolated from her classmates.

Clarissa had been meeting with her school’s learning specialist to improve her study strategies. Their plan included reading aloud , drawing pathways , organizing notes in space and by color , utilizing review books , completing practice questions, and handwriting a brief log of each small group session. Although implementing these techniques proved helpful, Clarissa still struggled to keep up with coursework and performed poorly on exams. Concerned she may be at risk for dismissal from medical school, she increased her financial aid loan to move forward with the neuropsychological evaluation. The report revealed multiple deficits in written and verbal language processing and evidence of ADHD. The neuropsychologist recommended several accommodations, including extended time on exams in a reduced distraction environment and the use of text-to-speech technology.

Clarissa met with the official who approved accommodations at her institution. Unfortunately, this person was not specialized and had no expertise beyond approving the accommodations suggested by the student’s evaluator. Thankfully, the accommodations recommended by the neuropsychologist were approved for the didactic setting, and once implemented, Clarissa’s examination scores improved drastically. As her grades increased, her feelings of isolation and anxiety lessened. Clarissa successfully passed her first- and second-year courses allowing her to stay on track with her graduating class.

Although Clarissa successfully completed the didactic portion of the curriculum, she has been struggling in her clinical rotations. While patients appreciate her calm demeanor, advocacy, and people skills, Clarissa struggles with time management, prioritization, and finishing notes on time. She is also taking longer than her peers to complete clinical work, like chart review and writing patient notes, leaving her with little time to prepare for shelf examinations. Clarissa’s attendings notice her struggling to manage duties on clinical rotations and are worried about her self-care (e.g., sleeping, eating healthily, and maintaining mental health and well-being).

Her clerkship director approaches her about these issues; however, Clarissa feels uncomfortable sharing the specifics of her disability with someone in an evaluative position. While the school had adequately addressed Clarissa’s needs in the didactic portion of the curriculum, they had never accommodated a student with learning and attention disabilities in a clinical setting and assumed that accommodations in the clinic were not reasonable. The student affairs dean and learning specialist are stumped, and without the aid of a disability resource professional who understands clinical accommodations, Clarissa fears she may fail.

Identifying Barriers from All Perspectives

Perspective of the Student

Perspective of the Medical School

Perspective of the Disability Resource Professional

Deconstructing Barriers and Access Issues

Starting the Process

What do you know?

What do you need to know?

How and where might you find new information that may lead to enhanced access?

What Do You Know?

Clarissa is a third-year medical student who just started clinical clerkships.

Clarissa’s diagnoses include deficits in written and verbal language processing and ADHD.

The student received accommodations in preclinical courses, including 1.5× time on examinations in a reduced distraction environment and use of text-to-speech programs. After implementing these accommodations, her academic performance increased significantly.

Clarissa is from a low-income family and has expressed feeling a sense of otherness from her medical school peers.

In clinic, patients and attendings appreciate Clarissa’s calm demeanor, advocacy, and people skills, but she struggles with time management, prioritization, and finishing notes in a timely manner.

Clarissa takes longer than her peers to complete clinical work, leaving little time to prepare for shelf examinations.

Clerkship attendings have noticed her struggling to manage duties on clinical rotations and are worried about her self-care (e.g., sleeping, eating healthily, and maintaining mental health and well-being).

Her clerkship director approached her, but Clarissa does not feel comfortable divulging personal details of her disability to a faculty member in an evaluative position.

The institution has not designated a DRP with specific knowledge of disabilities, current assistive technologies, and clinical accommodations.

What Do You Need to Know?

What are the competencies required of students in each specific clerkship? How do time management skills, meeting deadlines, and keeping up with the case load factor into these specific competencies?

Do the technical standards and/or professionalism competencies address time management skills, meeting deadlines, and/or keeping up with the case load?

Is there a policy on deceleration of clerkships? If so, who would need to join a discussion to determine if/how an exception may be made due to a diagnosed disability?

Is there a policy on protected time to ensure students in clerkships are able to tend to self-care, including medical appointments?

Are there other offices/services/resources that may be able to provide additional support to Clarissa?

Is there a way to allow her protected time to study for shelf exams?

Are there any legal mandates for accommodations in a clinical program?

How and Where Might You Obtain New Information that May Lead to Enhanced Access?

Potential Campus Partners

Office of Student Affairs

Office of Medical Education

Clerkship Dean

Clerkship Directors

Wellness Team

Office of Academic Support

Peer tutoring/mentoring programs

Office of Diversity and Inclusion

Associations and organizations that work with disabled learners

Potential General Resources for the Institution and the Student

Coalition for Disability Access in Health Science Education

Near-peer institutions with medical school-specific disability providers

Society for Physicians with Disabilities

Twitter, searching #DocsWithDisabilities

Twitter groups for disabled physicians

Additional Discussion Questions

1.

Does your program discussclinical accommodationsat the start of the program?

From Chap. 4 in Disability as Diversity:

Hiring a qualified disability resource professional for clinical programs is critical. Students requesting accommodations in health science programs (e.g., medicine, physical therapy, nursing, dentistry, pharmacology, occupational and physical therapy, and others) often encounter complexities that are unique to the course of study. DRPs must have a broad awareness of, and facility with, these areas. These complexities may include nuanced and variable clinical environments, restrictive or confusing technical standards, clinical competencies, and licensing requirements that result in varied thresholds of reasonableness when determining accommodations.

Additionally, DRPs without extensive health science backgrounds will likely be unfamiliar with accommodating students in novel assessment environments such as clinical rotations, clerkships, internships, preceptorships, standardized patient exams, and objective-structured clinical examinations (OSCEs) , which may make determinations about reasonable and effective accommodations in the clinical environment more challenging. In order to implement a thorough and well-informed interactive process, DRPs must develop expertise in the aforementioned clinical and legal domains and must spend considerable time learning about their respective health science programs.

Had Clarissa’s school employed a qualified DRP, clinical accommodations could have been discussed immediately, considering creative and current assistive technologies. See Chap. 4 for more information on qualified DRPs in health science programs, including a job description.

2.

Who is involved in the discussion aboutclinical accommodations?

At times, schools may involve everyone in an attempt to find the right answer. Clinical faculty and administrative partners may be great resources, but it’s important to balance this involvement with the need for student privacy.

From Chap. 4 in Disability as Diversity:

Some schools utilize a committee approach in determining reasonable accommodations. When using a committee, a DRP should ideally lead the committee in order to reduce potential bias, to ensure a robust and fair process, and to inform best practice in the area of disability resources in health sciences. In these instances, the DRP can share the functional limitations and barriers experienced by the student, but should not share diagnostic documentation. The literature suggests a number of concerns regarding committees including the sharing of information and sensitive documentation among individuals who may, at some point, have an evaluative role. Additionally, students may be hesitant to disclose disability or request accommodations if they know that a committee of faculty or deans will be making the determination. Even when steps are taken to protect privacy, the perception that a group of individuals will review their documentation may be enough to keep students from disclosing a disability. There are additional drawbacks to using a committee approach. When faculty members are involved with the committee, having prior knowledge of a disability can lead to unconscious bias and actions toward a student that may be expressed in more subjective evaluations or opportunities. Faculty may also unknowingly start to view the student in the role of a patient and unintentionally treat them differently. In addition to relational concerns, there may also be legal concerns about the use of a committee. For example, if a committee substitutes their clinical knowledge for the recommendations of the treating provider and fails to approve an accommodation request as a result, the required interactive process has not been followed. Committees may also meet at defined time intervals, such as monthly, which may result in delays for decision-making, which, in a fast-paced health science program, can prove costly to the student.

Read more about who should be involved in the process and what that process should ideally look like in Chap. 4.

3.

When students transition from preclinical curriculum to clerkship curriculum, is there any process to reevaluate their needs for accommodations in the clinical environment?

Functional limitations look very different in varying environments. If an evaluation has not already been conducted for clinical portions of the program, a DRP or representative should do so well in advance of the student entering the clinical environment. For students who require adaptive or assistive technology, these can be tried out in the simulation lab, giving all parties more confidence when deploying them on the wards.

From Chap. 10  in Disability as Diversity:

Students with ADHD may find it difficult to compensate for the large volume of information that must be reviewed and retained in health science programs. Those with a hyperactive clinical feature may, unintentionally, struggle with professionalism expectations in these new , high-stakes settings. For these students, accommodations offer a removal of barriers in the clinical settings. In addition to accommodations, students can employ strategies that mitigate the impact of their ADHD on functioning in a clinical setting.

Accommodations for ADHD include written, specific objectives or clinical expectations for a rotation, broken down by the week, with weekly feedback on progress. Feedback is best when it is delivered orally and in writing and presented as objectives met and objectives unmet with specific instruction on the steps needed in order to meet a learning objective or clinical competency [11]. Depending on the level of the student, checklists may be appropriate as a means of developmental scaffolding, while the student learns a new skill or process. Developing relationships with new teams and learning new systems or expectations, especially if these are only implied, are difficult for students with ADHD. Therefore, minimizing change, when possible and appropriate, can help the student