Disability and Medical Education, Part 2

Join us for Part 2 of our conversation with Dr. Lisa Meeks, a leader on disabilities in medical education and our friend from the Docs with Disabilities podcast, which she founded and co-hosts. Dr. Meeks discusses the prevalence of disabilities across the training and career spectrum, the risks of disclosure that students and physicians with disabilities face, and the resources of which we should all be aware for ourselves and for those around us.

Learning Objectives:

1. Investigate the prevalence of disabilities among physicians at different stages of their training and careers.
2. Recognize some of the challenges and risks associated with disclosure of one’s disability.
3. Build awareness of the repository of reliable resources on physicians with disabilities, disability access, accommodations, and stories that one can utilize for themselves and share with trainees with disabilities who are looking for resources.

Credits:
Guest: Dr. Lisa Meeks
Host/Associate Producer: Dr. Candace Sprott
Executive Producer: Dr. Tammy Lin
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman
Senior Producer: Dr. DJ Gaines
Production Assistants: Dr. Erynn Beeson, Dr. Andrea Anampa-Guzmán, Sanika Walimbe
Website/Art Design: Ann Truong
Music: Chris Dingman https://www.chrisdingman.com

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[0:00] : Dr. Candace Sprott: Welcome back to The DEI Shift. I'm Dr. Candace Sprott, an Internal Medicine and Pediatrics physician practicing in San Diego, California. And I'm an Associate Producer of The DEI Shift. This episode picks up the conversation about disability and medical education with Dr. Lisa Meeks. She's an Associate Professor at the University of Michigan, who is a leading researcher on disability in medical education, the executive director of the Docs with Disabilities Initiative and podcast of the same name. We were discussing her 2021 JAMA Network open article titled “Estimated Prevalence of U. S. Physicians with Disabilities.” If you haven't yet listened to our first episode, please go back and do so, as we pick up that conversation now.

Dr. Lisa Meeks: The other thing about this paper that you didn't mention that I would like to quickly mention, if that's okay, is that, you know, 3.1% seems small, it is small. But it, it's even smaller when we compare it to the people who are willing to self identify as disabled in the training continuum. So, in the UME space, we have about 10%. In the GME space, we have about 9%. And then we get to physicians and it's 3.1%. So what's happening here, right? And we're, we're just starting to look at this particular phenomenon. And I have a few ideas, right? Are trainees moving from a supportive environment into such a toxic environment that they choose to leave medicine? Is that what's happening? Are the, the consequences, the repercussions for being “found out” that you're disabled, are those so fearful that people are not willing to disclose anymore? Once they get out of the safety of the training space is the training environment. Conversely, is the training environment improving so much, are we doing such a good job at the level that more and more people are willing to disclose? So, and we just haven't gotten to that, to that space yet and in the workplace and, and I don't know, I don't, I don't know what the answer is.

[2:30 - 4:11] : I think, you know, this data is all being collected by the AAMC, and the AAMC does an incredible job maintaining the privacy of this data. All data are de-identified. There's absolutely no way to connect a data point to a particular individual yet. I can understand. And I think most people could understand why someone, as they're filling out a survey may hesitate, right, and may not believe that their data is safe and that the fear of being discovered is so real and so heavy that they're not going to self disclose. When we live in a society where we can see the text messages right on page six of People Magazine of one of the richest men in the world, who you would think would have incredible security, how does student X, you know, weigh the, the reality of they have no power, no privilege in this space yet? If Jeff Bezos text messages can be discovered, my data may be at risk. And they tell us that. So we have, we have, you know, open responses in some of our AAMC data collection. And that we have some papers coming out on this. The students tell us, “Look, I'm afraid to disclose even on this particular survey.” So again, we're looking at data. We're doing the best we can. But I think when, when we think about the data, we always have to view it through the limitations as you would with any research project, but the limitations of the society and the context in which we're asking these questions, which is not a safe environment for people with disabilities.

[4:11] : Dr. Candace Sprott: I really want to touch on that as well because you've, you know, we've shared in different arenas that, you know, the safety, physical and psychological, for disclosure is paramount. What are some of the experiences that folks have undergone when they have disclosed in this arena, because I'm thinking through this and wondering our audience may be wondering, “Well, why not disclose and get the support you need?” What are some of the experiences that have happened if you're comfortable kind of sharing from your work in that arena?

Dr. Lisa Meeks: Absolutely. I have a recent experience that was not my experience but was reported to me by multiple parties where a student disclosed a disability prior to matriculating to a medical school. Did so in good faith, right? “Here, I have this disability.” The accommodations were not outside of the scope of reasonable, in my opinion, and we've established I've written most of the best practice. So it's like, while I'm not going to claim that expert, you know, it's, it's, it's a fine line. I will say that based on what I reviewed, there was nothing that was not reasonable. And in fact, multiple people with the same disability have graduated and matched into residency and gone into practice in every single specialty, every single specialty. So this is not someone entering medicine where we have to worry about, “Can we graduate a pluripotent trainee?” And because this trainee was honest and wanted to engage in the interactive process to determine reasonable accommodations, I will just say they were met with skepticism. They were given the onus, and this happens in multiple situations, where the onus then becomes placed on the learner to determine what they need. Right? This learner's never been to medical school. They don't know what they need. But the full responsibility of how are you going to fit into us is placed on the student, and then the student is frantically - and this is how I found out about it, right, through my network - the student’s frantically reaching out to people like, “What would I need?” That's not the responsibility of the student; we don't ask them to prove that they can deliver a baby or do a rectal exam or throw a stitch; we don't ask other people to show that they can do these things. The minute we have a candidate who has a physical disability, we throw everything at them. “Tell us how you're going to do this. Tell us how you're going to do this. Tell us -.” They have to come to the conversation armed with information that they should not be responsible for, right? We assume that they're incompetent, and we don't do that with other people.

And, you know, to be honest, if somebody shows up - you know, I sit on the Executive Admissions Committee at Michigan - if a candidate shows up in our space and says, “I already know how to do a rectal exam and deliver a baby and throw a stitch,” I have some questions. Like if they're an emergency responder, okay. If they've been in the military, okay. That might cover some of it. I'm probably still going to have some questions. No, we don't expect people to show up to medicine knowing how to do all of this stuff. It's an educational program. So why do we constantly question people with disabilities? And they may need nothing. I just wrote a case study with a student and a group who were marvelous, a big shout out to the Cleveland Clinic. It was, it was just incredible. And the person needed almost nothing. They needed some furniture moved out of the way and some help with doors that were not accessible, right? Going back to, they would not have been disabled if the environment were accessible, if there were a push button. So why do we do this to other candidates? So that's one example.

Then let's say we have a student with a psychological disability and they disclose, “I'm a student with bipolar disorder, this is what I need for access in the training environment.” And let's just say part of that is “I need sleep hygiene,” which we know for individuals with bipolar disorder, that sleep hygiene is absolutely necessary and essential to maintaining wellness, reasonable accommodation and medical education, well-vetted across the country. But what's going to happen to that learner? Well, they could enter an environment where this is not a big deal as some of my learners at UCSF did, you know, “Okay, this is very reasonable. Let's get this all taken care of. No big deal.” Or they could enter an environment - I've seen this multiple times - where their ability to even become a physician is questioned the minute they disclose that diagnosis. All of the sudden it's, “Ooh, well,” - the dreaded words - “what's going to happen in the real world? What's going to happen in residency? They won't allow this. Well, the ADA extends to residency. So yes, this may be a reasonable accommodation, but also how are you going to be a practicing physician?” It's so sad to me. It's so sad. And I, I do think our learners with psychological based disabilities are those that are the most at risk.

And I would say our research supports that while it's the largest group, that group is only willing to disclose having a psychological disability if it's anxiety. If it's depression, if it's bipolar disorder, schizophrenia, something along those lines, we see far less numbers when we know statistically from other studies that 25-30% of our learners are going to have symptoms that rise to the level of a diagnosis of depression. So those are some of the ways in which this enters.

Dr. Candace Sprott: And that makes so much sense when we think about just the stigma that goes along with, as we talked about before, very hard to imagine a learner coming into an environment with 1) they may not know, they may have an undiagnosed condition that impacts them during the rigor of medical school, and not knowing where to turn or even how to advocate for themselves. And as you mentioned, you know, the medical school environment may be helpful and supportive, but what about residency or even vice versa? Or what about as we practice? So, so many levels where support and resources and a shared understanding of what that learner needs is important. I know that we are getting towards the end of our time with you, and I just want to finish up with a few final thoughts. And thank you, of course, for the time you spent thus far.

[11:24] Dr. Candace Sprott: Where can learners, um, allies, get more information and resources about what they may be facing, where they may have experienced retribution or backlash for disclosing? Can you direct our listeners to some resources that are available, uh, from your experience and your writing them, I'm sure?

Dr. Lisa Meeks: Well, I will say, while I'm so grateful that the ADA protects people against discrimination, litigation is almost - almost, because there are instances where it's been very helpful and helped push the needle - it's almost always the worst move to make right out of the gate. And, and that's just relationship 101, right? If I come to you and I'm on the defense and I have, you know, I'm like, you can't X, Y, Z, it's only going to result in you becoming defensive. And so education is my kind of go-to in this space. And unfortunately, we are in a situation where I think learners have to come to the table prepared to have conversations that they shouldn't have to have. So just understanding where your functional limitations are, if you have done some sort of shadowing or clinical work, having your letter-writer speak to that to dissuade any concern about your ability to be in medical school. Um, I find learning from others is one of the most valuable resources out there.

And so at the risk of sounding like I'm being, you know, promoting my own, my own resources, I will say the podcast, I think has been one of the single most rewarding things that I've ever been part of. And I receive feedback every day from learners that say it was game changing to them to listen to someone who looks like them, has their same disability, comes from the same background, all of these things, and to listen to how they navigated the system, kind of lessons learned, advice. At the end of our podcast, every interviewee gives advice. And this form of asynchronous mentoring, I think, is invaluable, especially in a space where we have so few physicians with disabilities. So I'm always so grateful for the people who are willing to share their stories. Um, a huge thank you to them. And we've started this program where, again, you know, I've talked about how I'm not the expert, the people with the disabilities are the experts. So we, we started a program where it's giving back the mic. And so we've started asking some of the people that we've interviewed to then turn around and interview someone else. Some of those stories which have already been published are some of the most compelling conversations I have ever heard in my life. It's very real. The authenticity is incredible. It doesn't feel like an interview. It feels like two people having a deep conversation about what it means to be disabled in medicine. And so I would really recommend that resource.

[14:50] : I also highly recommend the group called MSDCI. It's a, it's a group of medical students that advocate for disability access in medicine nationally, and they have different chapters at different medical schools. So that's a fantastic group. They're our resources. Pete Polis runs a mentoring program that is a wonderful resource for people looking for mentorship and advice from those who have already navigated the system. Of course, our website, docswithdisabilities.org, under Resources, we are crowdsourcing every single thing that's out there on disability inclusion and creating videos, one pagers. All of the podcasts, this podcast interview will go on there. Anything that is on our site, you can use for educational purposes. I often will say to students, I can't possibly provide advice directly to students. I receive on average 10 emails a week from students wanting resources and advice. And of course, we send them to all of these spaces, but they can use our resources and use our words and use our publications to inform what they need for their particular situation. And so I always encourage people to use the resources that are available.

[16:25]: I would say, yeah, that the storytelling I find to be one of the, the biggest resources. I would also invite people and invite the listeners here to go beyond the traditional allyship. Being an ally is great, you know - but in so many spaces, it doesn't change what's happening, right? To say, “I feel for you, I understand what you're going through” is one level of support, but to become an accomplice, to use your privilege, to challenge the existing conditions, the inaccessibility - that's powerful. And, you know, I have an example from a situation that happened actually, uh, at a school that I was at where something was inaccessible for a student that was hard of hearing. And instead of waiting for the student that had the inaccessible situation happening because so often these students don't want to make a fuss, don't want to, you know, challenge the system, a group from the entire class - it was a pretty big representation of the entire class - went to the administrators and said, “We do not want to learn in a space that is inaccessible.” And essentially demanded the captioning be added. And it was.

I would say to the medical students, and the other allies, you are so much more powerful than you think. And, and there's a beauty in kind of a collective response. And I think that's how real work gets done, whether it's anti-racism, anti-ableism, anti-homophobia, that when we come together as a community and say, we stand for these ethics and these rights, and we won't tolerate being in an educational environment or a training environment where people's rights are not protected and people are othered through whether it's racist actions or through inaccessibility -- that has the power to change the world.

Dr. Candace Sprott: That's beautiful and so well said moving from allyship and empathy to action, and that there is strength in numbers. And that even when you think you have no power, uh, potentially as a medical student or even a pre medical student, you do, and you can lead from where you stand.

[19:05] : I want to thank you so much for your time today, Lisa, and the information and thoughts that you shared with our audience and the resources. And I want to give you the time for any closing thoughts that you may want to leave with our audience?

Dr. Lisa Meeks: Oh, thank you. Well, first of all, thank you so much for having me. Thank you so much for highlighting this topic. I want to say that, you know, for everyone that's going to be creating, developing resources or events around Disability Employment Month or Disability Awareness, or when you're thinking about doing those, don't forget to include people with disabilities in those conversations. So often, I'm invited to give a talk. I'm not a physician. I have a PhD, as you mentioned at the beginning. So be sure to center any of those types of activities in the population. So physicians with disabilities, students with disabilities, and be sure to, to make sure that you're paying attention to the intersections of multiple marginalized groups when you do so, because disability cuts across every identity.

I do want to encourage the listeners to investigate some really important people who are coming up in medical education. If you're interested in this topic, certainly our group does a lot of research, and we're so proud of the research that we do, but it is very, very focused. We have not published as much on the kind of the bigger picture, the 20,000 foot perspective of what's happening, building theory, things of that nature. But there are two really important people who are doing that. And I would be remiss not to mention them. One is Dr. Justin Bullock. And he has a new paper literally out, I think, today, July 30th. And the paper's title is “‘Yourself in All Your Forms’: A Grounded Theory Exploration of Identity Safety in Medical Students.” It covers so much of what we've talked about today, feeling safe in an environment where you can then be your authentic self and create the support system around you that you need for access or for safety or whatever the case may be. But this research article is in Medical Education and it's open access, which is even lovelier. So anyone listening today can read it. And I encourage you to not only read this, but to follow Justin's story. He's a physician with a disability and mental health disability, and he is changing - and I don't say this lightly - he's changing academic medicine for the better. So definitely follow that rising star.

And then someone else near and dear to my heart, on the same trajectory, Dr. Neera Jain published a paper that really put forward a new theory called “legibility,” and the whole context of it is: how medical education perceives disability serves to create the environment that everyone is entering. And so again this exchange of need for accommodation or safety around accommodation is a theme that is in this paper. And the title of this paper is “Legibility: Knowing Disability in Medical Education Inclusion,” and it's in the Journal of Advances and Health Science Education, and I believe it looks like this is also open access, which is wonderful. So I just really encourage people to follow these leaders. Certainly, follow everybody in our lab because they're amazing. We have such an amazing group of individuals, about 90% identify as disabled, and many are coming to us from multiply- and traditionally-marginalized or minoritized identities, and we are doing the hard work, will continue to do the work. It's all in the service of others. But definitely check out these other two people that are just really shaking up academic medicine for the good.

Dr. Candace Sprott: A big thank you to Dr. Lisa Meeks for her time and insights today, as well as her team, at the Docs with Disabilities Initiative for their work in this space. To our listeners, please check out this episode's Show Notes for the additional resources mentioned during our discussion. If you love this episode, tell us. You can find us at The DEI Shift on X, formerly known as Twitter, and Instagram, or you can email us at thedeishift@gmail.com. Please email or tweet our team with your comments.