A Novel Medical Student Assistant Accommodation Model for a Medical Student With a Disability During a Required Clinical Clerkship

ABSTRACT

Background

As efforts continue to diversify the physician workforce so that it better matches the patient population, the number of medical students with disabilities will increase. U.S. medical schools and emergency medicine (EM) clerkships should be prepared to provide full and meaningful access to learners with disabilities.

Methods

We created a novel means of providing access to a senior medical student with a mobility disability (secondary to a cervical spinal cord injury) to participate in a fourth‐year EM clerkship. We hired four second‐year medical students as intermediaries to perform senior medical student–directed physical examination maneuvers, during his 15 required 8‐hour emergency department shifts. The senior medical student dictated his documentation using Dragon Natural Speaking (Nuance Communications, 2015) voice recognition software.

Results

The senior medical student successfully completed the required clinical clerkship and earned a honors grade for his work. Both the senior medical student and the second‐year medical student intermediaries gave positive feedback about the experience.

Conclusions

Given the significant prevalence of disability among medical students in U.S. medical schools, medical educators should provide greater access to students with disabilities and opportunities for advanced education for all learners by creating innovative clinical curriculum. The authors recommend the student intermediary model for senior medical students with physical disabilities in required clinical clerkships.

The prevalence of disability among medical students in U.S. medical schools is significant, with percentages ranging from 2.7% to 12% of all students.1, 2, 3, 4 However, this prevalence is likely even higher due to underreporting.5 Furthermore, there has been a recent increase in attention to the disparity in prevalence of disabilities between U.S. physicians and the general population. Nineteen percent of Americans identify as a person with a disability and recent research demonstrates that patient outcomes likely improve from an increase in physician–patient concordance similar to those with concordance in other marginalized populations.6, 7, 8, 9, 10, 11 As efforts to improve the diversity of the physician workforce to better reflect the patient population and decrease health care disparities among underrepresented populations continue, the number of medical students with disabilities will increase and so too must U.S. medical schools’ and emergency medicine (EM) clerkships’ ability to provide meaningful, equal access to learners with disabilities.12, 13, 14 We define disability, in accordance with the American with Disabilities Act (ADA), as a physical or mental impairment that substantially limits one or more of the major life activities of such individuals, a record of such an impairment, or being regarded as having such an impairment.15 The barriers that students with disability face are many and complex, including physical, structural, attitudinal, and behavioral.1, 16 The ADA requires schools to reasonably accommodate the disabilities of their students unless doing so would fundamentally alter a program or result in undue hardship.1 However, a recent Academic Medicine document analysis of all U.S. medical schools’ technical standards found that only 33% of schools stated a willingness to provide accommodations, while the remaining schools published ambiguous (49%), unsupportive (5%), or no language (14%) about providing them.3 Additionally, of the schools with available information regarding intermediaries, most (84%–86%) proscribed against intermediaries.3 Judicially, several recent court leanings found in favor of the defendant, upholding the school’s responsibility to afford qualified medical students with disabilities reasonable accommodations to ensure equal access to a program.17, 18, 19

We enrolled an undergraduate senior medical student, with a physical disability, in a 4‐week required EM clerkship from August to September in the 2017 to 2018 academic year. Although published undergraduate medical education curricula exist addressing patients with disabilities, we are unaware of an EM clerkship curricular innovation for medical students with physical disabilities available in the literature to date.20

Development and Implementation

The clerkship directors engaged in an interactive process1 as the guiding framework to create a novel accommodation experience for a senior medical student with a mobility impairment secondary to a cervical spinal cord injury to participate in a fourth‐year EM clerkship. This process began with an individual meeting with the senior medical student and the clerkship directors to discuss the daily routine for students on the clerkship and the access needed to perform the essential elements of the clerkship, such as accommodations to navigate the physical environment and to perform necessary physical examination maneuvers, documentation, and procedures. The senior medical student and the clerkship directors subsequently visited the ED to identify specific workspace barriers, including computer access and access to patient rooms.

After this preliminary needs assessment, the senior medical student and the clerkship directors met with a working group of representatives from the School of Medicine Student Affairs Office, the Disability Resources for Students Office, and the Curriculum Office. This group identified other necessary accommodations, including a voice recognition software that the senior medical student was familiar with. The group also determined that the optimal manner to meet the clinical requirements (fifteen 8‐hour emergency department [ED] shifts) was to provide an intermediary to the senior medical student. The group then drafted an intermediary job description (see Data Supplement S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10426/full). The clerkship directors reviewed the drafted responsibilities for the intermediary role with the senior medical student, confirming that he was in agreement. The position would report to the Disability Resources for Students Office staff and the EM clerkship faculty. The School of Medicine, via the Disability Resources for Students Office, funded the intermediaries’ wages at $17/hour. The local minimum wage at that time was $15/hour. Together, with the group of representatives above, the clerkship directors determined that the provision of access required for the student to participate in the clerkship would not impose an undue administrative, financial, or other hardship to the EM clerkship or the School of Medicine.

The clerkship directors chose to have second‐year medical students serve as intermediaries. Second‐year medical students at our school have completed 1 year of “Foundations of Clinical Medicine,” which encompasses the foundations of clinical skills, as well as a longitudinal primary care practicum, which includes a weekly primary care clinic where they see patients with preceptors. Thus, they have familiarity with medical terminology as well as clinical medicine and have had proctored experience with medical interviewing and physical examination skills. In addition, this opportunity has the added benefit of learning for the second‐year medical students. Health care professionals who encounter persons with disabilities often have more progressive attitude toward them than those who do not.21 As such, having the second‐year medical students act as intermediaries allows them to work alongside a peer who identifies as having a disability, creating a space for these future physician to learn about, and potentially erode, any stereotypes that they may have about persons with disabilities.

The intermediary position was posted at our institution, and second‐year medical students were encouraged to apply via group e‐mails. Four intermediaries were hired for the role, all of whom had previously sought out shadowing opportunities in the ED and thus had additional familiarity with this clinical and educational environment. The clerkship directors decided on this number of intermediaries to maximize continuity for the senior medical student while minimizing time demands for the active second‐year students. We will henceforth refer to the second‐year medical students hired as intermediaries only as “intermediaries,” rather than “medical students,” for clarity purposes.

The clerkship directors met with the senior medical student along with all four intermediaries to orient all parties to the objectives of the clerkship and the roles and responsibilities of the intermediaries and to answer any questions. During this time, it was clarified that the role of the intermediaries was to assist the senior medical student and that they should be mindful to avoid extraneous comments during shifts and to save clinical questions for after the shift.

Scheduling

The clerkship directors considered the intermediaries’ own class schedule when making the schedule for our senior medical student and avoided overlap with class hours as much as possible. They divided the 15 shifts for the senior medical student among the four intermediaries, assigning each three or four shifts over the 4 weeks. All shifts were in a single university teaching hospital’s ED.

Shift Setup

Intermediaries met the senior medical student at the beginning of each shift and accompanied the student throughout the shift. They assisted with computer sign‐in and station setup as needed, retrieved printed documentation from the printer, and accompanied the senior medical student on all patient care tasks.

History and Physical Examination

The intermediary accompanied the senior medical student to see all patients and assisted as needed with opening doors or moving gurneys. The senior medical student introduced himself and the intermediary and asked all history questions. For the physical examination, the senior medical student directed the intermediary to perform physical examination maneuvers, and the intermediary verbally reported all findings.

Documentation

The clerkship directors require students to write a note on each patient they care for during their EM rotation. At the time of this curricular innovation, clerkship directors required all students to type their notes into a Microsoft Word document on a secure computer in the ED and then delete them after printing for supervising physician review. The senior medical student used Dragon Natural Speaking (Nuance Communications) voice recognition software to dictate notes into Microsoft Word, and then the intermediary printed the documents out and handed them directly to the supervising physician for review.

Procedures

The senior medical student had previously met competency in specific procedures prior to their injury (laceration repair, IV placement, incision and drainage of an abscess). Therefore, the clerkship directors did not ask him to repeat these procedures during the EM rotation. The student was able to discuss in detail the indications for specific procedures on patients who needed them and read required supplemental material for each procedure.

Assistant Communication

The intermediaries developed a confidential group document to constantly share lessons learned for making shifts run well, to keep track of the schedule, and to stay in communication.

Outcomes

We evaluated the experience in three ways: 1) We assessed the student’s clinical performance. 2) We assessed the senior medical student’s perception of access in the rotation, and 3) we assessed the second‐year medical students’ experience serving as intermediaries. The metrics for evaluation used to give the senior medical student this grade were the same metrics used for all students rotating in the clerkship. The senior medical student earned an honors grade for his advanced clinical management skills. Historically, only 25% of students rotating in our EM clerkship earn a honors grade. Comments from his evaluation include:

“He did an extraordinary job on our shift together, seeing far more patients than most students usually see in a shift. He charted immediately and efficiently, keeping up with charting while taking ownership for the care of his patients. He was thorough and knowledgeable while also being open to feedback and learning."

"Focused, emergency appropriate clinical reporting (pertinent positives + negatives sorted appropriately), used clinical decision rules (PERC). Worked well with RNs."

"Excellent student with broad foundation of knowledge and communication skills. Some of the best presentations I've heard. Great job updating family and patients."

Unstructured qualitative feedback about the experience from the senior medical student was extremely positive. We did not wish to compromise the rotation and evaluation experience for him by formally studying his experience while he was being evaluated academically, so we opted to interview him at the close of the rotation after we had submitted his grade. He reported meeting all learning objectives without significant difficulty and recognized the value of the voice recognition software, which he described as efficient and effective. Furthermore, he continued to apply the intermediary model developed during his EM rotation the following year during his internship with rotating medical students at his new institution.

We interviewed all the intermediaries following the clerkship. They were also positive about their experience, reporting that it provided invaluable clinical exposure and prepared them for future clinical rotations.

Reflective Discussion

Lessons Learned

Transferability of this model to other institutions may be limited by resources and the timing of specific clerkship experiences. Providing equal access for the EM rotation necessitated funding for intermediaries, minor administrative support, and an estimated 8 hours of additional faculty time. This did not constitute an undue hardship for our program or our school. However, because determination of undue hardship is based on the individual nature and cost of an accommodation, as well as the structure and resources of an individual institution, less‐resourced schools may need to consider other reasonable accommodations beyond our intermediary model.22 Structurally, our EM clerkship is well‐timed as it occurs in the fourth year, after the senior medical student had completed all other required clerkships save for neurology. This made it possible for us to confirm that he was competent in skills‐based requirements. It may be worth exploring, however, which skill‐based requirements for medical students with disabilities are necessary if they are destined for specialties that will not involve the medical school–required skill.

Next Steps

We present a model for accommodating students with physical disabilities in the clinical environment, pairing second‐year medical students with a senior medical student. The model has the potential to be used in other clerkships, in residency programs, and in practice. It also has potential to expand our ability to increase diversity in medical education and practice to better reflect the diversity within our patient population. In addition, this model has the added benefit of breaking down stereotypes our students and/or faculty may have about persons, including patients and/or colleagues, with disabilities. Involving learners with disabilities in the education of learners without disabilities adds valuable insights about providing patient‐centered care and access to persons with disabilities.23 Further experience and study should examine the extent of disabilities for which such a program would work and how to construct systems that support successful access on a broader scale.

The authors thank Alexis Rush and Kristen Seiler in their essential administrative and collaborative contributions to make this innovation a success.

Supporting information

Data Supplement S1. Clinical assistant job description.

AEM Education and Training 2020;4:275–279