Residents With Disabilities: A national survey of directors of emergency medicine residency programs.

Background. The Americans With Disabilities Act (ADA) has been in effect since 1990. The present study shows response to this act for emergency medicine (EM) residents nationwide.

Methods. A total of 121 surveys were mailed to the directors of American College of Graduate Medical Education (ACGME)-approved residency programs. A definition of disability was provided, and a second mailing was sent to those not replying.

Results. Ninety-two program directors (76%) responded, representing 4,644 residents. Of these, 62 residents (1.3%) were reported as having a documented disability. Programs with a known disabled resident were significantly more likely to have available resources for assistance. Forty-seven (52%) of the program directors suspected a resident might have an undiagnosed disability; and 40 (85%) of these recommended testing or referral.

Conclusions. There is a wide array of disabilities among EM residents. Available assistance varies. This may apply to other residencies as well.

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ACCORDING TO the Americans With Disabilities Act (ADA) of 1990, (1) which came into effect in 1992, individuals are considered disabled if they meet one of the following three criteria: (1) if they have a physical or mental impairment that substantially limits one or more of the major life activities; (2) if they have a record of such an impairment; or (3) if they can be regarded as having such impairment. People in all professions have disabilities and overcome them to varying degrees. This includes medical students and physicians. (23) The number of EM resident physicians with disabilities is unknown. The purposes of this study were to determine the number and types of disabilities in EM residents and to assess actions taken by program directors to assist those residents. The study hypothesis was that programs that employed residents with known disabilities would offer significantly more support services to all residents than those programs not reporting disabled residents.

METHODS

This study was a cross-sectional design in the form of a national survey of all EM program directors. The study was performed from April through September 1999. The Human Subjects Review Committee approved the study as exempt. The study population included the directors of the 121 EM residency-training programs identified nationwide from the American College of Emergency Medicine website as being approved by the ACGME.

A cover letter, survey, and self-addressed stamped envelope were sent to each EM residency director. In the cover letter, disability was explicitly defined according to ADA guidelines. If the first survey was not returned within a 2month period, a second survey was mailed to the site requesting the same information in an effort to increase response rate. To maintain confidentiality of the survey, data were coded using numerical information known only to the investigators. No personal identifying information on either the program or residents was sought on the surveys.

The survey (Appendix) contained questions about the number of residents in the program, criteria for choosing residency applicants, whether the program has had a resident with a disability any information about the disability, any special testing accommodations, suspicions of undiagnosed disability, discrepancies between clinical skills and test performance, and assistance for those not passing boards.

Categorical data were reported as frequencies. A 2-tailed chi-square test was used to make comparisons between programs reporting at least one disabled resident and those not reporting any disabled resident. Ninety-five percent confidence intervals were calculated comparing the percentages of residencies that offered assistance to any resident who did not pass boards.

RESULTS

Responses were received from 92 (76%) of the 121 ACGME-approved residency programs in EM. There was no response from 29 (24%) of the programs. The response rate improved from 55% to 76% after a second mailing was sent.

The mean number of years of program director tenure was 5 [+ or -] 4. The mean number of applicants for the entering class of 1999 for the programs was 447 [+ or -] 202.

Residency screening tools are summarized in Table 1. Although the majority of residency directors stated there were minimum qualifications for their residency applicants, 60 (65%) stated that an interview could be obtained under special circumstances, mostly by a trusted faculty member recommendation or by rotating at their site.

The 92 responders oversaw a total of 4,644 residents during their tenure as program director. Of the 4,644 residents, 62 (1.3%) were reported as having a known diagnosed disability. Thirty-eight (61%) of the disabilities were diagnosed before residency, 22 (35%) during residency, and 2 (6%) unknown or not stated. Those with disabilities diagnosed before residency were more likely to graduate on time than those with disabilities diagnosed during residency (Fisher's exact test P < .001).

The breakdown of the disabilities is shown in Table 2. The majority of disabilities were learning disabilities (18, 29%), depression/bipolar disorder (8, 12.9%), and musculoskeletal conditions (6, 9.7%).

Of the 62 residents with disabilities,49 (79%) have either graduated or are expected to graduate on time. Of the remaining 13 residents, 5 required an additional 2 to 12 months during residency, 5 left the residency program, 1 transferred, 1 was fired, and 1 died. In 11 of these 13 residents, the disability was diagnosed during residency.

Nine (15%) of those with disabilities (8 learning, 1 attention deficit/hyperactivity disorder) required special testing accommodations of increased time to take examinations. In contrast, 4 residents without diagnosed disabilities were given special testing accommodations: increased time (3), and a private testing room (1).

Programs with a resident known to have a disability were more likely to have known available resources for assisting residents who did not pass boards (60% versus 32%, P = .013 using chi-square 28%, 95% CI = 8%-47%). Methods of support described were extra tutoring, practice testing, or board reviews (31 of 42). Other support listed included individual work with faculty advisor (6 of 42), specific counseling (5 of 42), and neuropsychiatric testing (4 of 42). Two thirds of programs listed more than one type of assistance.

Forty-seven (52%) of 91 program directors (1 did not respond) suspected a resident might have a disability not yet diagnosed, and 38 (84%) of them recommended testing or referral of at least one resident. Those directors who oversaw a resident with a known previously diagnosed disability were not more likely to suspect undiagnosed disabilities in other residents (P = .36 using chi-square). Those programs with an EM resident with a suspected undiagnosed disability were not more likely to have available resources for assisting residents who do not pass boards (45% versus 43%, P = .29 using chi-square). Sixty-seven program directors (73%) noticed a large discrepancy between the clinical abilities and board scores of at least one resident.

DISCUSSION

Disability is defined under the ADA as having a physical or mental impairment that substantially limits one or more major life activities. A physical impairment is a physiologic disorder that affects a body system such as a special sense organ. A mental impairment includes specific learning disabilities, documented emotional illnesses such as depression, and addiction to drugs or alcohol. Excluded are current use of illicit drugs without addiction and minor or temporary impairments. (1,4) We found no published data on residents with disabilities.

In this study, EM residents had diagnosed disabilities in 1.3% of cases. It is unknown how many medical students have a disability, though one study on physical disabilities estimated a prevalence of 0.2%. (3) However, that study was based on a response rate of 60% of medical schools with suspicion of underestimation, it was not intended to include all types of disabilities, and it was done before the ADA was implemented. Since implementation of the ADA, requests for testing accommodations for the MCAT (5) and NBME (*) have substantially increased, suggesting an increase in the number of individuals with disabilities in medical school and presumably residency training. Medical schools have also increased their services to students with learning disabilities. (6)

For this study, the most commonly reported disability for EM residents was learning disabilities. It is not uncommon for learning disability to be diagnosed for the first time in medical school or residency, one sign being poor performance on standardized examinations that is inconsistent with predicted performance. The second most common disability was depression or bipolar disorder, which we expected to be higher given the stress and demands of the medical profession. However, we suspect this number might be underreported because of societal and professional stigma and the ability to hide this condition.

Most disabilities (38 [61%]) were diagnosed before residency (how disclosure was obtained is unknown), though a substantial number were diagnosed or occurred during residency (22 [35%]). Many program directors accepted qualified applicants with disabilities, consistent with the tenets of the ADA.

The majority of residencies claimed use of a minimum score for at least one standardized examination (ie, 90% for NBME step 1, 75% for step 2) to screen residency applicants (Table 1), though 65% stated exceptions could be made based on a recommendation from a faculty member or by rotating at their site. This may be helpful especially for the learning disabled students who have poor standardized test performance but excellent clinical abilities.

Under the ADA, all education programs that receive federal funding are required to provide reasonable accommodations to those with disabilities. Of the 62 disabled EM residents, only 9 required testing accommodations in the form of extended time. Accommodations were also provided to 4 residents without disabilities, which might suggest hidden or undiagnosed disabilities. Several program directors mentioned offers of increased time that were declined by residents with learning disabilities. It appears that the cost to make these simple testing accommodations was small.

Tutoring and additional time for testing were most often cited as available support services. A surprisingly large number (more than half) of program directors suspected an undiagnosed disability, and the majority appropriately recommended testing or referral for that individual. The number of these referrals that actually resulted in a new diagnosis is unknown and suggests an underestimation of the number of diagnosed disabilities.

Programs with a known disabled resident had more available assistance than those programs with a suspected undiagnosed disability. These results seem to suggest that the actual presence of a disabled resident, not simply the suspicion of one, causes program directors to become familiar with and make resources available to residents who struggle with boards. Programs that are not even aware of available resources are unlikely to be in compliance with ADA requirements

Program directors have a moral, ethical, and legal obligation to accommodate and work with residents who have disabilities. Residency applicants and residents cannot be rejected or excluded on the basis of their disability. Every possible reasonable accommodation should be made to allow a qualified disabled person to achieve and be hired for a job. (7) Defining what constitutes reasonable accommodations and how to accomplish the ADA guidelines is yet to be determined at many institutions. Our study showed a 1.3% rate of known disabled EM residents who had a wide spectrum of disabilities. Accommodations for those with disabilities varied by institution, though the programs with disabled residents had significantly more known resources available to assist residents. Many program directors suspect disabilities among their residents but do not necessarily have the knowledge or facilities to assist these residents.

TABLE 1

Requirements for Successful Resident Applicants

                           No.(%)

National Board Step 1      83 (90)
 Minimum requirement
National Board Step 2      69 (75)
 Minimum requirement
3rd year clerkship grades  72 (78)
 Minimum requirement
4th year clerkship grades  73 (79)
 Minimum requirement
Letters of recommendation  73 (79)
Research                   39 (42)
Rotating at your site      57 (62)
Alpha Omega Alpha          45 (49)
TABLE 2

Disabilities Among Emergency Medicine Residents (N = 62)

Disability                       No. (%)

Learning disability              18 (29)
Depression/bipolar disorder      8 (12.9)
Musculoskeletal                  6 (9.7)
Visual                           4 (6.5)
Auditory                         4 (6.5)
Speech                           4 (6.5)
Attention deficit/hyperactivity  3 (4.8)
 disorder
Cardiovascular                   3 (4.8)
Substance dependence             3 (4.8)
Neurologic                       2 (3.2)
Other psychiatric                2 (3.2)
Respiratory                      1 (1.6)
Endocrine                        1 (1.6)
Digestive                        1 (1.6)
Unknown                          2 (3.2)

(*) Written communication, Philadelphia, Office of Test Accommodations, National Board of Medical Examiners, September 25, 1997.

References

(1.) Americans With Disabilities Act, Public Law 101-336. 101st Congress. Washington DC, US Government Printing Office, July 26, 1990

(2.) Wainapel SF: The physically disabled physician. JAMA 1987; 21:2935-2938

(3.) Wu SSH, Tsang P, Wainapel SF: Physical disability among American medical students. Am J Phys Med Rehabil 1996; 75:183-187

(4.) Essex-Sorlie D: The Americans With Disabilities Act I. History, summary, and key components. Acad Med 1994; 69:519-524

(5.) Helms LB, Helms CM: Medical education and disability discrimination: the law and future implications. Acad Med 1994; 64:535-543

(6.) Faigel HG: Changes in service for students with learning disabilities in US and Canadian medical schools, 1991-1997. Acad Med 1998; 73:1290-1293

(7.) Losh DP, Church L: Provisions of the Americans With Disabilities Act and the development of essential job functions for family practice residents. Fain Med 1999; 31:617-621

RELATED ARTICLE: KEY POINTS

* Emergency medicine program directors legally should be in compliance with the Americans With Disabilities Act (ADA).

* From this nationwide survey of 4,644 residents, 62 (1.3%), had a disability. The majority of disabilities were learning (18, 29%), depression/bipolar (8, 12.9%), and musculoskeletal problems (6, 9.7%).

* Of the 62 disabled residents, only 9 required testing accommodations in the form of extended examination time. Accommodations, which varied by institution, were also provided for 4 residents without disabilities. This could suggest hidden or undiagnosed disabilities.

* programs who had residents with known disabilities had more available assistance than those programs with suspected undiagnosed disabilities.

* Since implementation of the ADA, which came into effect in 1992, requests for testing accommodations for the MOAT and NBME substantially increased. This suggested a possible increase in the number of individuals with disabilities in medical school and presumably residency training.

From the Division of Emergency Medicine, University of California, Davis. (Dr. Takakuwa is now with the University of Pennsylvania.)

Reprint requests to Amy A. Ernst, MD, UC Davis Medical Center, Division of Emergency Medicine, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817.