Perception of Tunisian Medical Students with Chronic Conditions: Pilot Study

Abstract

Background

Medical studies are hard to manage especially for students with specific needs. These students warrant some adaptations in studies and trainings in order to achieve learning goals. Studies showed they face structural and cultural barriers and stigma. Current efforts aim to encourage integration of these persons in order to increase diversity.

Objective

This study aimed to assess perception of Tunisian medical students with specific needs.

Method

Cross-sectional study through online questionnaire including learners affiliated to the Faculty of Medicine of Tunis (students, interns, and residents) who consider they have specific needs. This questionnaire was elaborated by authors and explored barriers faced by participants, needed help, and suggested solutions. Study respected consent and confidentiality.

Results

This study included 40 participants. Most of them (n = 32) were post-graduate (interns and residents). The most reported condition was mental disability (n = 14). Main challenges faced by participants were work time schedule, unhealthy lifestyle, and negative attitudes from peers and supervisors, and 19 felt victim of stigma. Reported specific needs were adapting work schedule and psychological support from peers, from supervisors, or from mental health professionals. Almost half of the participants did never disclose their difficulties (n = 21). Suggested solutions involved to have a counseling center within the faculty. Only 8 participants knew there was a new unit helping students with specific needs in FMT.

Conclusions

Despite efforts of the university, medical learners with chronic conditions still face many structural and cultural barriers to inclusion. Most participants suggested to have more psychological support from faculty.

Introduction

Medical studies involve high demands in academic studies and clinical rotations [1]⁠. Conditions of training are sometimes hard to manage with irregular time schedules, night shifts, and work under stress. Many medical students with disability have difficulties to cope with such conditions [2]⁠. These reasons may account for the limited number of persons with disability in medical education. Another reason would be the absence of inclusive policy in many universities that would deny access for students with visible disabilities [3]⁠. Removing barriers and fighting stigma would encourage learners’ disclosure and help them obtain specific aid that helps them achieve medical education goals [4]⁠.

Many universities are trying to implement programs to promote inclusion of persons with disability [5]⁠. These programs aim to identify people with disability, and encourage disclosure. However, many students with disability still face barriers to inclusion [6]⁠. These barriers can be categorized into structural and cultural barriers. Structural barriers represent the inadequate or unclear institution procedures [6]⁠. Doctors’ diversity was found to improve patients care outcome because they already have been patients and are more empathetic [7]⁠.

There is an international trend for inclusion in education [8]⁠. European countries implemented recent policies enhancing inclusion of persons with disability [9]⁠. They also made huge efforts to encourage diversity in higher education [10, 11]⁠. In Asian culture, traditional families sometimes consider disability as a problem and try to hide it, and thus are reluctant to accept rehabilitation services [12]⁠, even though governments and educational institutions are trying to fight stigma [13, 14]. In India, for example, there are places in medical schools reserved for students with disability [15]⁠.

Generally speaking, the literature is scarce about this topic. Most published studies that are specific to medical students are from the USA [2, 13, 16].⁠ Prevalence of persons who self-reported disability in medical education varied from 0.19 to 2.7% in studies [5, 17]⁠, depending on definitions and method used.

Many countries have governmental policies encouraging social integration of persons with disabilities in Africa [18]⁠. In Tunisia, there are common laws that promote inclusion of persons with disabilities in educational and professional fields [18]⁠. However, there are no specific policies for medical education.

The objective of this study was to address the perception of medical students with chronic conditions in Tunisia regarding barriers to their integration and suggested solutions.

Method

Study Design

This was a cross-sectional study performed during 1 month in September 2022 through an online query. A questionnaire was developed by the authors of the study using Google Forms, and was diffused online in social media pages involving medical students, interns, and residents affiliated to FMT.

Inclusion Criteria

This study involved learners affiliated to FMT which is part of University of Tunis El-Manar (UTM), including students, interns, and residents. Participants were asked to answer the questionnaire if they consider they have a disability or chronic disease interfering with medical studies.

Exclusion Criteria

Learners from other universities than UTM and learners who do not consider they have a disability were excluded. Physicians who finished residency were also excluded.

Description of the Questionnaire

The questionnaire was developed by the study investigators. They elaborated the questions based on findings of literature from similar studies with help of linguists [1, 19, 20]⁠. They also asked preliminary questions to 4 learners with disabilities who worked within authors’ Mental Health Department in Mongi Slim Marsa Hospital. Learners’ answers helped improve the questionnaire.

At the beginning of the questionnaire, participants are asked if they consider they suffer from a disability or chronic condition that can interfere with medical studies and warrant specific needs. If they answer positively, they continue to the rest of the sections. If not, the questionnaire is over. The questionnaire included a first section about general information related to participants then a section about type of disability and specific needs, a section about the help needed. Learners could also state if they found difficulties to disclose their disorders, if they got the needed help and from whom. A section was dedicated to cultural aspects and perceived stigma and a final section asked about the suggested solutions, with possibility to write a free paragraph. The questionnaire was in French language since medical studies are performed in French in Tunisia and all students are French speaking. French is the second language in Tunisia after Arabic. The authors decided not to use the French equivalent word of disability which is “handicap” alone, since it may be culturally perceived as stigmatizing. The word “disability” was always associated with “or chronic disorder” or “specific needs” (e.g., Do you think you suffer from a disability or chronic disorder that can impact medical studies?).

Ethical Considerations

This study obtained the validation of the ethics committee of FMT (approval number: CE-FMT/2022/02/ HMS /V2). The study respected the confidentiality and consent of participants. Ethical committee confirmed that authors should not use the word disability or disabled which can be perceived as stigmatizing from the participants themselves.

Results

Description of the Participants Sample

This pilot study included 40 participants. Mean age was 27.8 (min: 24; max: 31). Sex ratio was 0.8. Academic level and specialty of participants are presented in Table 1.

Table 1.

Description of participants’ sample

Academic level	Undergrad student 20% (n = 8)
	Intern 17.5% (n = 7)
	Resident 62.5% (n = 25)
Residents’ specialty	Family medicine 62.5% (n = 25)
	Medical specialty 20% (n = 8)
	Surgical specialty 7.5% (n = 3)
	Fundamental specialty 10% (n = 4)

Type of Disability or Chronic Condition

Participants were asked about the type of their disability or chronic disease. Most of them considered they had a mental disability (52%), or a motor disability (23%) (Fig. 1). Besides, the participants could specify if they suffer from other chronic conditions not suggested in the questionnaire. Reported conditions were asthma, Crohn disease and other colitis, rheumatologic chronic pain, migraine, auto-immune conditions, and gynecologic disorders. These conditions can be disabling if they are not stabilized.

Fig. 1.

Types of disability

Challenges Faced by Learners

There were 71% of participants who think that their disability interfered with medical studies. Physical and mental fatigue were the most cited difficulties. Other cited barriers were work schedule, relationship issues with peers or supervisors, or inability to take one’s medications or consult one’s physician (Fig. 2). Many participants also indicated they were unable to have a healthy lifestyle. Most of them (60%) reported difficulties during internship or undergraduate medical studies (30%). Main barriers according to education level are presented in Table 2.

Fig. 2.

Type of difficulties

Table 2.

Main reported obstacles depending on medical education stage

Stage	Main obstacles
Undergrad students	Unhealthy lifestyle, no time for sports or leisure Huge amount of topics for exams Busy schedule (studies and clinical rotations)
Interns	Lack of sleep due to night shifts Stress of medical responsibility Lack of understanding from supervisors and peers Inability to take medications and consult treating physician regularly
Residents (depends on the specialty)	Lack of sleep (in some specialties with several night shifts) Stress of medical responsibility

Needed Help

Forty percent of participants said they warranted psychological support, 30% would need adapted work schedule, and 23% wished to have complete or temporary exemption from night shifts (Fig. 3). Two suggested other help: available and clean toilets (n = 1) and a personal office (n = 1).

Fig. 3.

Type of needed aid

Only 45% (n = 18) felt they could find adequate aid from colleagues (n = 10), teachers (n = 3), or from faculty administration (n = 3). Two participants wrote they found aid from themselves or from family members. Only 20% knew there was a unit who helps learners with disabilities at the FMT and 90% did never get in touch with any kind of supporting network, either official or peer network.

Disclosure

Participants were asked if they ever disclosed their disorder and 52.5% (n = 21) answered “no.” Most of them were afraid of being stigmatized, or afraid of negative consequences on their career. However, 5% stated they did not need to disclose.

Stigma

We found that 47.5% of participants felt victim of stigma (n = 19). This perceived stigma was mostly from peers (n = 6), supervisors (n = 9), university administration (n = 2), or from patients (n = 2). Half of the participants felt they were aggrieved on their career because of their health condition. When asked if persons with disability can be doctors, 5 participants said that people with physical (n = 3) or mental (n = 2) disabilities are not able to be doctors.

Suggested Solutions

Most of the participants suggested a “counseling center” in the faculty that supports them in a comprehensive management of diseases including social security, providing medications, consultations, and psychological follow-up. Participants wished that “the supervisors should be aware of persons with chronic diseases in their team in order to adjust everyone’s workstation, and be more understanding”, and “peers could help each other”, and avoid judgment “Medicine sometimes lacks humanity because our peers and supervisors are those who judge us most.” Other suggested solutions were to avoid unbearable hours schedule and offer sufficient rest time. Four participants asked to provide psychological support and psychologists in every hospital. They considered it difficult to consult the psychiatric hospital because of time consumption (Table 3).

Table 3.

Suggested solutions

Main suggested solutions	Number of participants
Counseling center/psychologist in hospitals and medical school	12
Increasing awareness of supervisors and peers about students with disability	6
Adapt workstation/ reduce work hours and night shifts	6
Collaboration between supervisors and treating physician	2
Comprehensive support from university (social security, providing medications, consultations etc.)	1
No suggested solution	13

Discussion

Strengths and Limitations

This is the first pilot study about medical learners with disabilities perception in Tunisia. However, the recruitment process was difficult. Most learners with disabilities do not disclose their condition and are hence difficult to reach. There are no associations of medical students with disabilities. There are no comprehensive figures in FMT about prevalence or types of disabilities.

This study is based on participants self-report which involves subjectivity and the questionnaire is not validated. However, most published studies use similar methods [5]⁠. In fact, such studies try to catch lived experience of participants which is inherently subjective and there are no validated scales.

Type of Disability

Almost half of the participants self-reported having a mental disability (such as bipolar disorder) or chronic physical conditions. The concept of disability involves a broad range: physical, learning, psychological, or chronic diseases [21]⁠. It is a condition that impairs learning as compared to most other students. Most chronic conditions do not interfere with medical studies if they are well stabilized but can be disabling if they are not well managed. In Tunisia, prevalence of medical students with disabilities is low. In fact, people with disabilities or learning impairment do not always get necessary help during primary or secondary education. Hence, they rarely get high grade average on baccalaureate and cannot access medical studies. There is no inclusive policy that encourages enrollment of minorities in medical studies. This process depends only on baccalaureate average.

Challenges and Obstacles Faced by Participants

Most participants felt their disability interfered with their medical curriculum. Physical and psychological fatigue could be due to the underlying condition and aggravated by the stressful work and rigid time schedule [22]. Healthy lifestyle includes eating healthy meals at regular times, having regular sleeping time, and practicing workout. People with disability are the most impacted with stressful conditions [23]⁠. Some chronic disorders, such as diabetes or auto-immune conditions, warrant a healthy lifestyle and stress reduction in order to avoid relapse [24, 25]⁠.

Lack of understanding from peers and supervisors come under the cultural stigma of disability [26]⁠ and could be due to a lack of awareness about disabilities and principles of inclusive policy [19]⁠.

Some participants did not have time to take their medications or consult their treating physician. This could be due to the overwhelming work schedule or fear of stigma. Some learners try to hide their medications and appointments [26]⁠.

The most difficult period was internship according to 60% of our sample. Freshly graduating interns have sometimes to face alone stressful medical responsibility [27, 28]⁠. Interns choose training settings based on average ranking during the 5 years of undergrad studies, and not based on their preferences or capacities.

Specific Help Needed

Most participants wished to have a psychological support and adjustment of workstation. The challenge is to ensure adequate medical training while adapting work for specific needs [29]⁠. Guidelines help define reasonable accommodations that can be settled in healthcare settings in order to guarantee equity between students [30–32]⁠. Some adaptations, such as definitive night shift exemption, are considered inconsistent with adequate medical training [33]⁠. However, they can be limited to reasonable duration and learners could be supervised [34]⁠. Such agreements are often difficult to settle given the common lack of human resources in the medical field [35]⁠.

Perceived Available Aid

Only 18 participants felt they found adequate aid. Only 20% knew the existence of an office that could help them in the FMT. Besides, nearly half of the participants did never disclose their disorder and thus could not get help. In the absence of adequate accommodations, learners need to spend huge energy and time arranging their accommodations by their own [6]⁠. Even in universities that have implemented a pioneer inclusive policy for disability, there are still structural and cultural issues that hamper integration [6, 20, 36]⁠. Besides, our study found that no one of the participants was in contact with an association of learners with disability. Such advocacy organizations are useful to make their voice heard [6]⁠.

Disclosure

Only 19 participants disclosed their disorder. If supervisors do not know about trainees’ medical conditions, they will not be able to offer adequate help and there is a risk of relapse. This can be harmful for themselves and for their patient’s management. In case of psychiatric mood disorders, there is even a risk of suicidal behavior. The AAMC report found a lack of standardization in disclosure processes [19]⁠. It is necessary to implement a systematic and clear process of disclosure that encourages learners, ensures confidentiality, and prevents negative consequences on their career [5, 37]⁠.

Stigma

Nearly half of the participants reported perceived stigma either from peers or faculty members or patients. Learners with disabilities have long been considered a problem to solve in medical studies, while they should be perceived as a source of diversity beneficial for institution and patients [38, 39]⁠. In their published testimonies, medical students described how they were denied access to medicine school for deafness, or they were accused of laziness because of their severe fatigue due to an auto-immune condition. A student with bipolar disorder achieved to become professor of psychiatry and described barriers on her way [40–42]⁠.

There is also a part of self-stigma [38, 43]⁠. In this study, 5 participants stated that people with disability cannot be doctors. This may be explained by the negative impact of the word “disability” in our cultural context even in persons with disability.

Suggested Solutions

Many participants suggested to have a “counseling center.” FMT has created a unit to help students who have difficulties in their medical curriculum. It works in collaboration with students treating physicians. This office may not have enough resources to help all students in need.

This unit, called committee for students support, offered a tutoring service for 80 undergrad students since its creation 2 years ago. These students reported difficulties due to various reasons, not only disability. For example, they could have medical or social or familial issues. This tutoring is performed by trained supervisors.

Some faculties around the world have implemented disability service offices (DSO) [5]⁠. Their tasks are to check eligibility for enrollment into a program for learners with disability and then help eligible learners get the adequate help with collaboration of referent supervisors in clinical wards. However, there is often a lack of communication between the DSO and supervisors. Some offices do not have enough human and material resources or are in settings far from the faculty [6]⁠.

Participants suggested improving cultural aspects including human relationships with peers and supervisors and fighting stigma. FMT and three other faculties of medicine in Tunisia are implementing inclusive policies. UTM is planning courses for its teachers to train them help learners with blindness. FMT is implementing a program of tutorship to help medical students with difficulties.

Recent publications reported the use of technology to assist students with disability [16, 44]⁠. Virtual and augmented reality were used [44, 45]⁠. Implementation of these facilities can benefit all students [46]⁠.

Conclusion

Despite efforts of the university, learners with disability still face many challenges during their curriculum. Learners complained of negative attitudes from peers and supervisors. They wished to have more psychological support and help from faculty. There are many efforts from the faculty that are made individually in a case-by-case approach. A systematic, comprehensive institutional approach is recommended. The final goal would be to implement inclusive policies and implement the culture of disability to fight stigma.

Declarations

Competing Interests

The authors declare no competing interests.