Preparing to begin her fourth year of medical school this summer, "Christen" has started the process of applications, examinations and interviews in order to take part in the annual tradition known as Match Day, where thousands of medical school students and graduates learn which residency program they will enter for the next three to seven years of training.
Although she's excited by the prospect of taking the next step on her road to becoming a physician, Christen admitted feeling a bit intimidated by the application process.
"I am worried on multiple levels," said Christen, who spoke on the condition that her identity or the school she attends not be published. Christen was diagnosed with a learning disability after her first year in medical school, and it took nine months of evaluations at her own expense and calling multiple offices at her school before she finally received accommodations, such as allowing her extra time to complete her examinations.
Christen felt she did not do as well as she could have on the U.S. Medical Licensing Examination, known commonly as Step 1, because she did not ask for accommodations after being advised it was unlikely her request would be granted. That experience has made her anxious about what to expect as she gets further along in the application process, and the reactions she might receive when she discloses her disability to prospective employers.
"I am a little worried that someone's implicit bias might come into play if they're the ones holding my application at that moment," she said.
Medical students living with a physical or mental disability experience similar concerns over bias or stigmas well before they are ready to apply for residencies. Although they're entitled to accommodations under the Americans with Disabilities Act, research found many of these students reported it was difficult to access or find information that could help them with their medical education and maximize their potential as physicians. Others said they were fearful of asking for help because they felt doing so would cast them in a negative light among fellow students and faculty in a highly competitive environment.
Those fears and difficulties have led to students underreporting their disabilities and underutilizing support, according to a new report released this week by the Association of American Medical Colleges and researchers from the University of Michigan and the University of California at San Francisco.
An estimated 2.7% of U.S. medical school students identify as having a disability, according to a 2016 study published in JAMA. But the prevalence is much greater, according to report co-author Lisa Meeks, a clinical lecturer at the University of Michigan Medical School's Institute for Health Policy and Innovation. She said many students have opted not to disclose their disability out of fear it will reflect negatively on their performance or competency as a physician.
"Their model is the culture of perfection—the perfect physician who can perform without needing anything," Meeks said. "That's just not reality, but they (students) remain quiet, and they silently suffer."
The report found many medical schools lacked a clear set of policies and procedures regarding how students can access accommodations. Many institutions either did not have a dedicated person on staff that handled accommodation requests, failed to publicize information about accommodations, or did not have sufficient accommodations altogether.
"One of the important things about this report is that it really does amplify the call for disability to be really fully integrated within diversity and inclusion discussion at medical schools and teaching hospitals," said Geoffrey Young, senior director for student affairs and programs at AAMC.
The report recommended medical schools have an independent expert assess existing services to identify areas for improvement. Also, schools should create an environment where a student asking for help is seen as normal to help ease anxieties and concerns about requesting accommodation, according to the report. It also suggested schools offer time off for physical and mental health appointments.
When third-year medical student Dani Takai-Castioni matriculated in 2013, she had already been diagnosed with attention deficit hyperactivity disorder. She also needed to use a wheelchair once she began her medical education. She recalled presenters during her orientation only briefly mentioned where students could go to request help if they had a disability. She said it sent a message to her that students with disabilities were an afterthought.
Takai-Castioni was forthright from the beginning and asked for support, but she admits it was still difficult to know where to go for help since the school spent little time informing students about available resources.
"One of the things I think I benefited from was that right away I was very proactive in trying to figure out who the disabilities service providers were at my school and what accommodations I would be needing," Takai-Castioni said.
Under the Americans with Disabilities Act, it is up to the student to inform the school if they need accommodations, but the environment can make it uncomfortable for many students ask for help, she said.
Takai-Castioni said some schools are seeking to address those concerns by broadening their non-academic, technical standards, which are the criteria that medical schools expect students to meet, such as the ability to observe demonstrations, communicate effectively and perform calculations, along with strong motor skills and the emotional health to fully apply their intellectual skills.
A 2016 study published in the journal Academic Medicine found only 33% of the 146 medical schools studied had technical standards that specifically stated they supported accommodating disabilities.
"When you have the technical standards, there are things you really have to be able to do in order to be a physician," Takai-Castioni said. "However, the manner in which you accomplish that is not set in stone."
Meeks said one of biggest moves medical schools can make toward becoming more inclusive for students with disabilities is changing the culture on their campuses to show they are committed to recruiting, admitting and graduating such students.
"I think you have to change the narrative that is outward-facing, that the public sees, because a student with a disability that's thinking about applying to medical school is looking at that narrative," Meeks said.