Teherani A, Papadakis MA. Clinical Performance of Medical Students With Protected Disabilities. JAMA. 2013;310(21):2309-2311. doi:10.1001/jama.2013.283198
The Americans with Disabilities Act requires accommodations for students with protected disabilities. To inform conversations about the effect of disabilities and accommodations on performance by medical students, we sought to determine if clinical performance during the clerkship year and graduation rates differed between students with and without protected disabilities.
We conducted a retrospective cohort study at the University of California, San Francisco (UCSF). The UCSF institutional review board approved the research protocol and consent waiver. Between 1987 and 2009, approximately 3000 medical students matriculated to UCSF.
The director of student disability services elicits a detailed history of the student’s disability to determine qualification for accommodations. Students who matriculated with protected disabilities did so based on mental or physical impairment. Each student with a protected disability was matched to 3 students without protected disabilities based on sex, age, and year of matriculation1,2 for power of 80% and moderate effect size (η2 = 0.09, α = .05).3
Measures included demographics, bases for disability, Medical College Admission Test (MCAT) scores, graduation rate, first-attempt scores or pass rates on US Medical Licensing Examination (USMLE), and residency match rates. Clerkship directors submitted 13-item assessments at the end of 6 core clerkships. Each item was scored as 1 = inadequate; 2 = fair; 3 = good (passing); and 4 = outstanding. Data from 8 of the items were used to calculate mean composite clerkship assessment scores representing medical knowledge, data gathering, communication skills, and professionalism across clerkships. Data collection was completed September 2013.
We examined statistical relationships by using χ2 and Fisher exact tests, 1-way analysis of variance, and multivariable analysis of covariance.3 All tests were 2-sided with P < .05 used as the significance threshold. We used SPSS version 19 (SPSS Inc).
The study sample consisted of 59 students with protected disabilities and 171 students without protected disabilities. Demographics were similar for students with and without protected disabilities (Table 1). Of students with disabilities, 29 (49.2%) had mental impairment (22 [37.3%] learning; 5 [8.5%] attention-deficit/hyperactivity disorder; 2 [3.4%] psychological), 25 [42.4%] had physical impairment (7 [11.9%] mobility; 2 [3.4%] hearing; 1 [1.7%] vision; 15 [25.4%] other), and 5 (8.4%) had other impairments. The graduation rate was 86.4% (51/59) for students with protected disabilities and 99.4% (176/177) for students without protected disabilities (P = .001).
Students without protected disabilities performed better than those with protected disabilities on MCAT physical sciences scores (mean difference, 1.2 [95% CI, 0.6-1.8], P = .001), MCAT biological sciences scores (mean difference, 0.9 [95% CI, 0.3-1.4], P = .002), MCAT verbal reasoning scores (mean difference, 0.7 [95% CI, 0.2-1.1], P = .01), first-attempt USMLE step 1 scores (mean difference, 16.0 [95% CI, 9.2-23.0], P = .001), and USMLE step 2 clinical knowledge scores (mean difference, 12.4 [95% CI, 4.4-20.3], P = .002). There were no differences between groups in USMLE step 2 clinical skills pass rates or match rates into residency programs or primary care for those who graduated from medical school.
Students in all groups performed in the passing range (score ≥3) on their clerkship assessments (Table 2). Students without protected disabilities performed better than students with protected disabilities for mental impairment on data gathering (mean difference, 0.2 [95% CI, 0.002-0.3], P = .04) and communication skills (mean difference, 0.2 [95% CI, 0.01-0.3], P = .03). Professionalism and knowledge scores did not differ by group.
Most medical students with protected disabilities performed well clinically, graduated, and matched into residency programs. However, medical students with protected disabilities performed less well on academic achievement measures and were less likely to graduate than those without protected disabilities. The clinical clerkship performance of students with protected disabilities from mental impairment, but not from physical impairment, was below that of students without protected disabilities. However, the magnitude of the differences was small. Whether these differences portend difficulties in practice is unknown. The difference in graduation rates between students with and without protected disabilities was more notable.
The limitations of this study include that of a single institution design, small number of students with disabilities, and the power for a moderate effect. Students with protected disabilities may not have used accommodations.
The performance differences and accommodation needs of medical students with protected disabilities need to be better understood to increase the diversity of the physician workforce. Reasons for differences during medical school and subsequent performance during and beyond residency training should be assessed.
Corresponding Author: Arianne Teherani, PhD, University of California San Francisco, 1855 Folsom St, San Francisco, CA 94143 (firstname.lastname@example.org).
Author Contributions: Dr Teherani had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Teherani, Papadakis.
Acquisition of data: Teherani, Papadakis.
Analysis and interpretation of data: Teherani.
Drafting of the manuscript: Teherani, Papadakis.
Critical revision of the manuscript for important intellectual content: Teherani, Papadakis.
Statistical analysis: Teherani.
Administrative, technical, or material support: Teherani, Papadakis.
Study supervision: Papadakis.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We thank Eric Koenig, MS, Neera Jain, MS, CRC, Lisa Meeks, PhD, and Barbara Smith (all 4 with the Office of Student Life, University of California, San Francisco) for their help with clarifying rules and procedures for disability services and providing the data on accommodations; and Mark Lovett, MPIA (Office of Medical Education, University of California, San Francisco), for help with acquiring demographic and outcome data and merging with the data on accommodations provided by the Office of Student Life. None of these persons received compensation for their contributions.