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January 7, 1998

The Disabled Student as Undifferentiated Graduate: A Medical School Challenge

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Copyright 1998 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1998American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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JAMA. 1998;279(1):79. doi:10.1001/jama.279.1.79-JMS0107-3-1

More than 20 years have passed since implementation of the Rehabilitation Act of 1973,1 and it has been almost a decade since those protections were expanded by the Americans With Disabilities Act (ADA) of 1990.2 These statutes prohibit discrimination against a disabled but "otherwise qualified" person seeking admission to an institution of higher learning. Yet, physically disabled individuals continue to be denied admission to medical schools.

Students with disabilities account for 0.2% of medical school graduates.3,4 Considering that 8.8% of college freshmen have some disability, these reports suggest that a very low percentage of the physically disabled enter medical school.5

This resistance arises from the premise that the ideal graduate should be prepared "to enter without handicap any one of the fields of medical practice."6 Thus, every student is expected to acquire the knowledge and skills needed to enter any residency.7,8 Prospective students unable to become "undifferentiated graduates" may be excluded from medical school admission.

Under the ADA, reconsideration of the "undifferentiated graduate" concept has posed a serious challenge. ADA regulations obligate a faculty to review the school's curriculum, develop standards for admission, and apply those standards uniformly to all applicants. Simply stated, the ADA requires the following.9,10

  • Schools must judge applicants on their expected ability to complete the educational program, without regard to disability.

  • An applicant must be able to perform the "essential functions" of the curriculum.

  • A school must provide "reasonable accommodation, " so an "otherwise qualified " but disabled person is not prevented from completing the curriculum.

  • Reasonable accommodation does not require "fundamental alteration" of a program, or actions that impose "undue burden."

  • A school may not solicit information concerning disability.

  • A student requesting accommodation must present documentation including exact diagnosis; nature of impairment; specific recommendations for accommodations.

In 1979, a special advisory panel of the Association of American Medical Colleges (AAMC) responded to the 1973 Rehabilitation Act.8

The AAMC wrote that acceptable candidates required skills including observation, communication, motor function, conceptual, integrative and quantitative thinking, and appropriate behavioral and social attributes. The panel also concluded that a medical student should perform independently. Technologic compensation for handicaps was acceptable but assistants were not, since an intermediary might interpose "someone else's power of selection and observation" on a student's judgment.

These standards have inhibited acceptance of disabled students.11 A blind student, for example, required assistance to perform an "essential function, " the acquisition of visual information. Use of an intermediary was considered a "fundamental alteration" of the program.

The ADA provides an opportunity to rethink certain applications of these standards. For instance, decreased upper extremity motor function may require the use of assistants. Under earlier AAMC standards, such a student would not be acceptable. But under the ADA, the curriculum's "essential functions" may be more specifically defined: Is direct palpation by the physician necessary to conceptualize disease? Does use of an intermediary impair clinical judgment?

Indeed, in modern medical practice, support staff frequently collect data for the physician's interpretation, making the ability to work with intermediaries an asset.

Medical schools must determine how any qualified applicant, regardless of physical ability, can be effectively accommodated and counseled in achieving the most appropriate medical career. In this era of technologic diagnostics and professional assistants, the "essential functions" of medical education might be restated as acquiring fundamental knowledge; developing communication skills; interpreting data; integrating knowledge to establish clinical judgment; and developing appropriate professional attitudes and behaviors.

If carefully selected and supported, a significantly disabled student can succeed in a rigorous medical school program. An intermediary need not intrude on analysis and decision-making, and independent motor performance may no longer be an essential requirement.

Any student achieving these restated essentials could be an "undifferentiated graduate." If we succeed in effecting this conceptual change, all graduates will be prepared for residency and practice "without handicap."

Not Available, Not Available. 29 USC §794.
Not Available, Not Available. 42 USC §12101 et seq.
Moore-West  MHeath  D The physically handicapped student in medical school: a preliminary study. J Med Educ. 1982;57918- 921
Wu  SSHTsang  PWainapel  SF Physical disability among American medical students. Am J Phys Med Rehab. 1996;75183- 187Article
Henderson  C College Freshmen With Disabilities: A Statistical Profile.  Washington, DC American Council on Education, Health Resource Center1992;
Committee on Undergraduate Medical Education, Report to the American Surgical Association. Trans Am Surg Assoc. 1950;68523- 554
Association of American Medical Colleges,  Report of the Special Advisory Panel on Technical Standards for Medical School Admission .  Washington, DC Association of American Medical Colleges1979;
Association of American Medical Colleges,  Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree .  Washington, DC Association of American Medical Colleges, Liaison Committee on Medical Education1997;
Association of American Medical Colleges,  The Americans With Disabilities Act (ADA) and the Disabled Student in Medical School: Guidelines for Medical Schools .  Washington, DC Association of American Medical Colleges1993;
Association of American Medical Colleges,  The Disabled Student in Medical School: An Overview of Legal Requirements .  Washington, DC Association of American Medical Colleges1993;
Not Available, Ohio Civil Rights Commission v Case Western Reserve,. 66721 WL 716543 (1994).