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January 7, 1998

Substance Abuse, Mental Illness, and Medical Students: The Role of the Americans With Disabilities Act

Author Affiliations

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.

JAMA. 1998;279(1):80. doi:10.1001/jama.279.1.80-JMS0107-4-1

In 1973 the American Medical Association's Council on Mental Health defined impairment as "the inability to practice medicine with reasonable skill and safety to patients by reasons of physical or mental illness, including alcoholism or drug dependence."1 Today, medical student and physician impairment is still a major cause of concern, with alcohol and drug addictions representing 80% to 94% of all cases investigated by state physician impairment programs.2 Because the classification of addiction as a disease is still not widely accepted, impaired students and physicians tend to be seen as weak in character, rather than ill. The Americans With Disabilities Act (ADA) of 1990 offers an opportunity to assist and protect students with disabilities due to substance abuse or mental illness.

The prevalence of mental illness among medical students, including substance abuse, may differ from the general population in a few notable respects.3 For example, American medical students use alcohol, benzodiazepines, and prescription opiates at a higher rate than similar age-matched cohorts.4 As for other forms of mental illness, an 8-year study at the University of Louisville revealed that approximately 20% of their medical students sought psychiatric consultation and treatment, for reasons such as adjustment, mood, anxiety, compulsive and dependent personality disorders, and marital problems.5 It remains unclear whether medical students are more likely to develop mental health problems. Entrance requirements for medical school may select students with obsessive and narcissistic traits or an irrational fear of failure.6 Subsequent crisis and increased stress may elicit maladaptive behaviors, possibly leading to depression.

The ADA, first implemented in 1992, guarantees that individuals with disabilities receive equal opportunities in employment, public accommodations, state and local government services, transportation, and telecommunications. However, considerable debate exists over the degree of protection that the ADA may provide to impaired medical students.

For a student to be considered disabled under the ADA, he or she must have a physical or mental impairment that substantially limits 1 or more major life activities. A mental impairment is defined as any recognized mental or psychological disorder, including specific learning disabilities. Included as disabilities are recovery from alcoholism and addiction, as well as active alcoholism that does not adversely affect performance. Excluded are minor or temporary impairments; sex addictions; compulsive gambling; kleptomania; pyromania; and current, illegal use of prescription or illicit drugs.7

To qualify for ADA protection, the student must demonstrate that he or she has met all requirements for admission, can fulfill the fundamental requirements of medical education, with or without reasonable accommodations, and poses no direct risk of substantial harm to the health and safety of others.7 The student is responsible for obtaining a medical evaluation to determine if an impairment exists. The ADA then requires that schools make reasonable accommodations to help otherwise qualified disabled students overcome unnecessary barriers that may prevent or restrict educational opportunities. The ADA does not require lower performance standards, disruptive or cost-prohibitive accommodations, or a stress-free environment.8

For students already enrolled, medical schools may initiate a medical inquiry only after evidence of academic difficulty, actions not specifically covered by the ADA, or new evidence of a direct risk to the health and safety of others.9 Medical schools may dismiss disabled students who pose a distinct risk of substantial harm to the health and safety of others. They may also dismiss otherwise qualified disabled students when reasonable accommodations have been provided and the student cannot satisfy the fundamental academic requirements, or when no reasonable accommodation is possible.

Evidence shows that treated physicians are no more of a risk to the public than other physicians.10 A renewed effort is needed to encourage the acceptance of those disabled by substance abuse and mental illness and to focus on prevention, early detection, and treatment. Although seemingly cumbersome, implementation of the ADA should encourage the greater acceptance and assistance of medical students with disabilities.

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