12 Tips for Including Disability Awareness within Undergraduate Medical Education Curricula

Version Changes

Revised. Amendments from Version 1

The authors have edited this manuscript based upon comments from peer review. Caroline N. Harada who provided essential expertise to the revision process has been added as a co-author to the manuscript. The abstract was rewritten to remove specific data that would otherwise require a citation. The former Tip 2 was elevated to Tip #1 and edited to reflect the importance of incorporating persons with disability into all aspects of the curricular design, implementation, and assessment process. The former Tip 1 (now Tip #2) was retitled and restructured to highlight the importance of using a framework for the design and implementation of any disability awareness curriculum. The authors now describe the use of Kern’s six-step model of curricular development. The title of Tip 5 was edited for clarity. Aspects of the narratives of Tips 6, 7, 8, 10, 11, and 12 were edited for clarity based upon recommendations by the reviewers. An additional paragraph was added to Tip 9 to caution educators on the risk of promoting ableism when placing learners into disability simulation activities. Finally, additional specific information was added to Tip 12 to provide practical ways in which longitudinal experiences can be included within clinical clerkships and advanced electives.

Abstract

Disability is extremely common, and there is a need for high quality medical school curricula on working with persons with disabilities. The goal of disability training is to provide the proper knowledge and skills to address the unique needs of PWD, mitigate health disparities, and help shape more compassionate and informed physicians. This article presents 12 tips to incorporate disability training into undergraduate medical education. These tips emphasize the inclusion of PWD in all stages of the curriculum, interprofessional education, experiential learning, and exposure to a range of disability types. By leveraging these tips, educators will be able to create effective learning opportunities and improve the future healthcare of PWD.

Introduction

With an estimated population of approximately 50 million, persons with disabilities (PWD) comprise the largest minority group in the U.S. and contribute significantly to the diversity of U.S. residents ( Leppert & Schaeffer, 2023; Okoro et al., 2018). PWD face significant health care disparities due in part to their complex medical needs and barriers faced when accessing medical care. As a result, chronic diseases such as obesity, diabetes, and heart disease are more prevalent within this vulnerable population ( CDC, 2024). Physicians note that a variety of barriers limit their ability to provide effective care for these individuals, including knowledge gaps, challenges with communication, and a lack of accessible facilities ( McMillan et al., 2016). Approximately half of American medical schools have a disability curriculum, which may be why fewer than half of physicians surveyed in one study reported comfort when providing care for this population ( Holder et al., 2009; Seidel & Crowe, 2017). Early and frequent exposure of medical trainees to PWD, their unique health care needs, and barriers to effective care is one strategy to address these health disparities and improve medical care for these individuals.

The following 12 tips are provided for medical educators wishing to incorporate disability awareness into the medical training programs at their own institutions. These tips are based upon the authors’ experiences with disability awareness education in both undergraduate medical education (UME) and graduate medical education (GME) ( Parish et al., 2024; Sinha et al., 2024). These tips have been developed within the theoretical framework of intergroup contact theory (ICT), which stresses the importance of direct contact between minority and majority groups to break down prejudices and foster collaboration and shared understanding ( Pettigrew, 1998; Pettigrew & Tropp, 2006). A key tenet of any disability awareness program is the inclusion of PWD into every phase of the process, from development through implementation and assessment.

Tip 1 – Embed persons with disabilities into all phases of the curriculum

Coined during the disability civil rights movement, the slogan “nothing about us without us” refers to the idea that no policy should be decided without involvement of members of the affected group ( Chu et al., 2016). Multiple factors contribute to lower quality health care delivery to PWD, which contributes to further health care disparities and poorer health outcomes; these factors would be realistically modifiable with input from PWD ( Sharby et al., 2015). PWD must be included in all aspects of disability awareness curricula, including the planning, development (design and content), implementation, and assessment phases. Those who possess lived experiences and voices are most capable of making a longitudinal effect on future medical practice. Failure to engage with PWD can lead to the propagation of ableist ideas and distortion of the most important facets of disability and healthcare. Developing partnerships with local rehabilitation clinics and community centers are great ways to create professional contacts to foster a collaborative approach to disability awareness and recruit PWD to participate as educators.

Tip 2 – Follow Kern’s six-step method for curriculum development

As with any curriculum development process, a thoughtfully constructed plan is essential to ensure success. We recommend Kern’s six-step model ( Thomas et al., 2015). Step 1 is to conduct a general needs assessment for the medical school, and step 2 is to determine the specific needs of the medical students. Since every medical school is unique and medical students enter training from a wide array of backgrounds and experiences, there is no “one-size-fits-all" model for providing disability awareness education. A needs assessment survey and/or set of focus groups involving PWD, students, and other stakeholders can be used to tailor a disability awareness curriculum to meet the unique needs of each medical school. To ensure success, the recommendations of patients with disabilities in the local community should be solicited, to better understand what future physicians need to know. Although there are certainly recommendations that will be consistent from PWD across the globe, there may also be recommendations that are specific to a given community of which educators should be aware. For example, there may be specific cultural or institutional norms that medical students need to learn about for PWD in their community.

Learning objectives, step 3, should aim to address gaps in learner knowledge and align with programmatic learning goals. When identifying educational strategies, step 4, be sure that they align with the overall curricular approach and culture of your medical school to establish continuity of instruction and further contribute to success. For example, if problem-based learning (PBL) is a core curricular element of your medical school, then including patients who have disabilities in one or more PBL cases would be an appropriate strategy. If students routinely engage in service learning, then partnering with community centers that provide services to PWD would be a great option. After step 5, implementation, a well-executed evaluation plan is pivotal to determine successes and areas of growth and improvement. As noted in Tip 1, be sure to include PWD into each phase of Kern’s model.

Tip 3 – Utilize diverse clinicians with experience working with PWD

The Centers for Disease Control and Prevention classifies disability into six types: mobility, cognition, independent living, hearing, vision, and self-care ( CDC, 2024). Some medical and health professions, such as physical therapy, occupational therapy, speech-language pathology and physiatry, have specific roles in caring for PWD who have one or more of these disability types. Because of their prevalent roles working with this population, disability awareness is often an accreditation requirement and embedded within their training. For example, Doctor of Physical Therapy (DPT) programs integrate disability awareness, distinctively geared toward mobility-based disability, throughout their curricula ( Roush & Sharby, 2011). Therefore, in addition to PWD, it is helpful to integrate healthcare professionals who have experience working with this population into the disability awareness programs. This is particularly important as PWD often require a team-based approach to care that includes a variety of health professions ( Reis et al., 2004). Inclusion of clinicians who possess these experiences can help ensure that key considerations and clinical pearls are embedded within the curricula.

Tip 4 – Include Interprofessional Education (IPE) elements

Emphasizing an interprofessional approach when implementing disability awareness curricula is important, because caring for PWD often requires communication and planning as a healthcare team ( Iezzoni, 2006; Reis et al., 2004). IPE has been shown as beneficial to learning, skill development, and creating a plan of care ( McCave et al., 2019; Visser et al., 2019). It is also important for future physicians to understand the role of other healthcare professionals in treating PWD as it can allow for better patient-client management and referral for those who may have unmet needs. Since many medical schools have associated health professions programs, IPE activities can involve students from physical therapy, occupational therapy, speech-language pathology, nursing, and physician associate programs to name a few. Disability awareness activities provide a robust and practical setting to meet accreditation requirements around IPE.

Tip 5 – Incorporate a broad spectrum of disability types into the curriculum

Disability is neither a single diagnosis nor a single human characteristic. It is a collection of physical or mental impairments that limits life activities, and it can result from myriad illnesses and injuries. Furthermore, people with disabilities are just as diverse as those who do not have a disability. Educational programs that promote disability awareness should strive to be as inclusive as possible and represent the full diversity of this population. One way to do this is to include a breadth of disability types in your instruction and learning experiences:

• Mobility – You could incorporate wheelchair users (manual and powerchair) and have students self-propel themselves in wheelchairs around your educational building.

• Cognition – You could allow students to volunteer at community centers or other sites that provide services to individuals with intellectual and developmental disabilities.

• Vision – You could incorporate a patient with a vision impairment into a PBL or case-based learning session or allow students to volunteer at training sites for service animals.

• Hearing – You could provide a medical sign language class or allow students to practice working with an interpreter to communicate with guests who have hearing impairments.

When adopting Tip 1, be sure to engage a diverse group of PWD in the planning and implementation of the program, ensuring diversity of age, sex, gender, race, ethnicity, disability type, disability etiology (congenital vs. acquired), occupation, etc.

Tip 6 – Include a variety of pedagogies, emphasizing experiential learning

Understanding of disability awareness can be enhanced by using a multitude of pedagogies. While lectures, readings, videos or case studies might inform background information, such as the Americans with Disabilities Act (ADA) and communication etiquette, experiential learning provides hands-on experiences that can provide a unique method for learning. Experiential learning, including direct interaction between students and PWD, should be considered as a focal element of disability curricula. Furthermore, service learning and community outreach activities allow students to see and interact with PWD in non-clinical settings. Bringing PWD onto campus for small group discussions is another way to create valuable learning experiences.

Tip 7 – Ensure access to appropriate equipment and facilities

PWD often utilize assistive and adaptive equipment to help promote independence. As physicians are often the prescribers of equipment, it is imperative to have familiarity with types of equipment and spaces in which equipment is utilized. For example, a commonly prescribed piece of equipment for both short- and long-term mobility impairments is a wheelchair. Having various types of wheelchairs during interactive portions of disability awareness learning activities can allow students to use the equipment, which can spark discussion of costs, proper fit, and parts of wheelchairs that may be needed based on diagnosis. Similarly, gait belts and sliding boards are useful to have students practice how to transfer PWD on and off of an examination table. For language disabilities, communication devices should be used by students to experience how devices operate. Equipment integrated into the disability awareness curriculum should be diverse and based upon the type of disability being studied to allow for holistic exposure and understanding of the compatible devices that PWD may use.

Tip 8 – Introduce students to the Americans with Disabilities Act (ADA)

The Americans with Disabilities Act (ADA) is a civil rights law that was enacted in 1990 to prohibit discrimination against individuals with disabilities, ensuring that this population has the same rights and opportunities as those without disabilities. Title III of the ADA sets the minimum standards for accessibility of public and privately-owned facilities, directs businesses to make reasonable accommodations when serving people with disabilities, and requires appropriate measures be taken to effectively communicate with individuals who have speech, hearing and vision impairments. Introducing medical students to the basic tenets of the ADA is an essential component of any disability awareness curriculum as it forms the foundation for government-mandated accommodation and accessibility considerations. This should begin as early as new student orientation when medical students are made aware of disability support services for students and processes for obtaining disability-related accommodations. As topics around disability in healthcare and considerations for patients who have specific types of disability are introduced in the formal curriculum, additional details regarding the ADA’s role in protecting the rights of PWD can be incorporated through short videos or reading assignments. Other approaches that employ more active methods of instruction include one-on-one and small group conversations about accessibility with individuals who have disabilities and placing students into a variety of ADA compliant and non-compliant facilities. Longitudinal curricular elements such as clinical skills and learning communities offer opportunities for a threaded approach to education around the ADA. Our approach to teaching about the ADA includes both lecture-based content and experiential learning with early and longitudinal exposures.

Tip 9 – Simulate first-hand experiences by placing learners “into the shoes” of PWD

It is important to note that although experiential learning may allow a student to simulate what it is like to have a disability, it is not the same as living with a disability. For our approach, PWD help to create and lead experiential learning activities. This allows medical students to have a more meaningful learning opportunity versus inducing a sympathy-based response for individuals who live with disabilities. For our curriculum, physical therapy students teach medical students how to self-propel a wheelchair. Medical students then self-propel wheelchairs through their educational building alongside individuals who use wheelchairs for mobility. The wheelchair users guide students to experience the ADA-compliant and non-compliant aspects of buildings, sidewalks, and parking during this process. The wheelchair users then have an open dialogue with students to discuss the long-term effects of using a wheelchair for mobility, share their experiences, and answer questions. These meaningful learning contexts can improve student engagement, understanding, and retention of the material all while promoting deeper awareness of the emotional, social, and physical aspects of living with a disability ( Laurillard, 2012). Immersing students in these situations helps break down stereotypes, while building a sense of responsibility to improve the lack of inclusivity, the “non-disability-friendly” spaces, and increase patience in their future clinical practice.

Educators should be aware that disability simulation can also have the unintended consequence of promoting ableism and discrimination against PWD. This can happen because in simulation students experience becoming disabled, thus overemphasizing trauma of the experience, which can promote pity, negative stereotypes, and underemphasize the social inequalities experienced by PWD over time ( Silverman, 2015). Nonetheless, we feel that through thoughtful coaching and debriefing with PWD these unintended consequences can be avoided.

Tip 10 – Create opportunities for open dialog between learners and PWD

Creating opportunities for open dialogue between students and PWD who serve as the facilitators of learning experiences is crucial to fostering a more effective learning environment. These interactions help dispel misconceptions, bridge gaps between learners and facilitators, and foster more encouraging and accepting clinical practice. PWD are underrepresented as educators, but they may reflect images in the mirror for many students and help guide learners in understanding everyday challenges and triumphs for PWD ( Anderson et al., 1998). Open channels of communication in the learning environment help build collaborative relationships where facilitators and learners can discuss shared perspective and various views surrounding them as well as uncomfortable but necessary dilemmas ( Ta et al., 2023). Whether in the form of a panel discussion or experiential learning activity in pre-clerkship training, a simulated patient encounter, or an authentic clinical experience during the third- and fourth-years, there are ample opportunities within the four-year medical curriculum to incorporate these discussions and effectively utilize PWD as educators. Including a minimum of one learning activity in the pre-clerkship phase and several authentic clinical encounters in the third- and fourth-years is recommended. Through open discussions, everyone’s unique abilities and perspectives are acknowledged and integrated to better enhance learning.

Tip 11 – Embed reflective elements into the activities

Adding reflective elements, such as small group debriefs and reflection essays, into a disability curriculum can enhance an already dynamic and inclusive learning environment for learners and facilitators alike. For learners, research has shown that when students combine their learning with reflection, they are able to effectively understand and analyze problems that they could not otherwise ( Eyler & Giles, 1999). When students are encouraged to recognize their strengths and weaknesses and assess their learning through self-reflection, they are more likely to adopt those processes going forward ( Silverman & Cassaza, 2000). For facilitators, reflection provides structure to their teaching and encourages them to take responsibility for themselves. By understanding what is effective and what could be improved upon, reflection helps educators create more inclusive curricula with greater relevance and direction for their learners ( Daudelin, 1996). Reflective elements can easily be incorporated as part of experiential learning sessions (Tip 6) and open dialogue sessions (Tip 10). Ideally, reflection as a formal or informal learning element should accompany each component of a disability awareness curricular thread. Overall, incorporating reflective elements in a disability-based curriculum can enhance the experience for learners and stress continuity while also contributing to the professional growth of PWD as educators, creating a more refined ecosystem.

Tip 12 – Create longitudinal experiences

Currently, only half of U.S. medical schools have a disability awareness program ( Seidel & Crowe, 2017). For those that do, most incorporate training within the pre-clinical years but fail to provide experiences in the clinical phase of training, which limits opportunities for application in clinical practice. Both the lack of education and continuity adds to the negative bias and discomfort that many medical students and physicians feel when treating PWD; this only results in worse healthcare and medical attention for PWD ( Sharby et al., 2015). The ineffective nature of continued medical education contributes to the discrepancy between evidence/experience-based knowledge and fair practice ( Marinopoulos et al., 2007). Thus, it is vital that schools not only incorporate disability training early in medical training but thread these experiences longitudinally throughout training.

During the core clinical clerkships, ensure that students have the ability to interact with patients of all disability types. Internal medicine, pediatrics, and neurology clerkships, in particular, should offer ample opportunities for students to participate in the care of PWD from each of the six categories defined by the Centers for Disease Control and Prevention ( CDC, 2024). Asynchronous learning modules and simulated patient encounters can be used as supplements when students are unable to work with a specific type of disability. For example, embedding a patient who has a hearing or vision deficit or who uses a wheelchair into a simulation activity that already takes place within a clerkship is an effective way to add depth to a simulation without adding curricular time. Students should also participate in the development of management plans alongside physical or occupational therapists during their acting internships to strengthen their understanding of the complexities of caring for this patient population. Advanced electives in the care of PWD during the fourth year of medical school can provide further opportunities for students to deepen their skills prior to residency training.

Conclusion

The goal of these 12 tips is to provide medical educators with the necessary tools to promote students’ awareness of unique considerations when providing care for PWD and foster a platform for PWD to function as key participants in the learning environment. It is crucial that medical schools prepare the next generation of physicians to provide effective health-care for this population through diverse teaching and learning methods, interprofessional collaboration, and a focus on reflection and continuity. By embracing these tips, the teaching and learning process can become enriching for all stakeholders and cultivate trainees who will be compassionate and confident providers within their future roles.

Ethics and consent

Ethical approval and Consent were not required.

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

Data availability

No data are associated with this article.

Notes on contributors

Tanvee Sinha is a third-year medical student at the Marnix E. Heersink School of Medicine, University of Alabama at Birmingham. She is also pursuing a Master of Public Health degree. She plans to pursue a residency and career in Physical Medicine and Rehabilitation.

Caroline N. Harada, MD is Professor in the Department of Medical Education at Marnix E. Heersink School of Medicine where she teaches health equity. She is Associate Dean for Strategic Initiatives in Medical Education.

William S. Brooks, PhD is Professor in the Department of Cell, Developmental & Integrative Biology at the University of Alabama at Birmingham where he teaches gross anatomy. He is the Assistant Dean for Preclinical Education in the Marnix E. Heersink School of Medicine.

Ashley Parish, DPT is Assistant Professor in the Department of Physical Therapy at the University of Alabama at Birmingham where she teaches in the areas of pediatrics and cardiovascular and pulmonary content and interventions. She is a Certified Cardiovascular and Pulmonary Clinical Specialist and works clinically at UAB STEP Clinic and a local hospital.