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BCH Academy Spring Retreat – Ensuring Inclusion of Health Professional Learners with Disabilities

LORI NEWMAN: The aim of today’s retreat is to explore our current landscape and perceptions towards learners with disabilities. The experiences of disabled practitioners in health professions, education, and practice suggest that there are many barriers to inclusion. And these barriers may lead learners with disabilities to fear disclosure, restrict their career choices and their educational and learning progress. Our hope is through this afternoon’s discussion, we can address those barriers, as well as our own biases and assumptions about disabilities, and discuss ways to overcome challenges for our learners.

I would now like to introduce our speakers. We are so honored to have our three speakers today. And I will start with Dr. Jennifer Arnold. Jennifer received her medical degree from Johns Hopkins School of Medicine and then completed a pediatric residency program and neonatal/perinatal medicine fellowship at Children’s Hospital of Pittsburgh and Magee-Womens Hospital.

During her fellowship, she also obtained a Master of Science in Medical Education from the University of Pittsburgh in 2008. She moved to Houston to start up the Pediatric Simulation Program at Texas Children’s Hospital as its inaugural medical director. After nine plus years, she relocated to her hometown of St. Petersburg, Florida to lead Johns Hopkins All Children’s Hospital new Center for Medical Simulation and Innovative Education.

Then in January 2022, she made the very wise move to come here to Boston Children’s Hospital to be the program director for SIMPeds. She has received funding for simulation educational research and published for her work in health care, simulation as a patient safety tool and educational tool for patient and family-centered care. Thank you so much, Jen, for joining us today.

Then it is my pleasure to introduce Bonnie Crume. Bonnie is a second-year pediatric gastroenterology fellow here at Boston Children’s Hospital. Bonnie’s clinical interest is deaf and hard-of-hearing advocacy. Thank you, Bonnie, for joining us today.

And then it is my honor to introduce to you Dr. Lisa Meeks. Lisa is an expert in disabilities in health professions education. As an administrative leader and researcher, she is helping to inform policy and best practices nationally and internationally in the area of disability inclusion for health professions, education, training, and practice. Her research interests include improving access to education for learners with disabilities, students and resident well-being, reducing health-care disparities in patients with disabilities and the performance and trajectory of health professional learners and practitioners with disabilities.

Her work has been published in the New England Journal of Medicine, Lancet, JAMA, and Academic Medicine. And she has been featured on NPR, along with many other national news outlets. Lisa is the cofounder and past president of the coalition of disability access in health science and medical education. She edited and authored the leading books on the topic, including Disability as Diversity and Equal Access for Students with Disabilities– The Guide for Health Science and Professional Education. It is an absolute honor to have Lisa join us today.

I also want to thank Alan Leichtner, Eva Gomez, Ellen Brennan, and Joey Fournier for their time and support of today’s retreat. So with that, I’m going to stop sharing and turn this over to Lisa Meeks.

LISA MEEKS: Good morning or good afternoon. What a pleasure to be here. And thank you so much. I think a huge run of applause to Lori and Joseph for helping with the planning of this event today.

I’m really excited to be able to introduce you to our learning objectives, what we hope that you will learn during our time together today. And that is to be able to identify accessibility barriers in health professions education and clinical learning environments, to identify mechanisms for improving disability access in clinical education, and to evaluate and address individual training programs to improve access and the inclusion of all learners.

And we have a very full day in our time together. Obviously, we’ve just introduced our speakers and the goals and objectives of the day. And so our next big event is for the keynote from Dr. Jennifer Arnold. And then we’ll move into some of the personal accounts of the accommodation process at BCH. And that will be from Bonnie. And then hospital policies and learners, that will be from Lori again.

And then we’ll have a small break. And then when we come back, we’re going to do some breakout groups. I will talk for a little while. And then we’ll have a Q&A.

And the lovely thing about our Q&A is in striving to create a really safe environment where you feel free to ask the questions that are at the front of mind for you, we have engaged Poll Everywhere. So all questions will be anonymous. We’ve left a ton of time for Q&A. I know Jen and I, and I’m sure Bonnie and everyone on the team as well, are really excited to just engage with you and answer those questions that you probably have been holding for a while.

All right, so that’s it for now. And I’m going to turn it over to Dr. Arnold.

JENNIFER ARNOLD: Well, thank you so much, Dr. Meeks. Thank you for having me, oh my goodness, today, Laurie and everyone on the academy team. And it’s just great to be a part of this very important topic and workshop.

So I’m going to bring up my slides. I do have some slides. And just sort of reference, my talk today is really going to be a story. It’s a very personal story of mine. And I hope that as I go through my story that it not only resonates with everyone in the audience– and hopefully you can take away how this might apply to your own story. But I hope it gives us some good discussion starting points as we talk about the very important topic of individuals with disabilities in medicine.

So my personal story, I’ve sort of framed it in the concept of overcoming obstacles with optimism and under this motto called THINK BIG, no pun intended, as a person of short stature with a skeletal dysplasia. My disability is essentially that I have spondyloepiphyseal dysplasia, which results in not only short stature– I’m only about 3 foot 2 when I round up with my clogs on– but I also have a lot of orthopedic complications as a result of my skeletal dysplasia. So I’m going to share with you my personal journey towards getting into the field of health care and medicine and to becoming a physician.

So this is me on my first birthday. And I, again, apologize. There will be a lot of personal family photos of myself as I share my story.

But when I was born back in, gosh, the 1970s, no one really knew at that time what my challenge was, what my disability was. But I had a lot of– I wasn’t growing on the growth curve. I was in a lot of distress at birth, probably had hydrops– as a neonatalologist, I have surmised from my parent’s description of what was going on– and was intubated in the NICU for quite some time.

But my parents, I was very fortunate in that I think my family and my parents, despite not knowing what my condition was for quite some time, really saw me like any other child and expected me to accomplish whatever it is that I wanted in life. And so they taught me very early on to be the kind of girl that likes to have her cake and eat it, too. And, and as you see in this picture on my first birthday, I ate that whole piece of cake.

But if you think about having your cake and eating it too as a person with a disability, at a very young age or a very early age, I knew that I wanted to give back because I had, due to my skeletal dysplasia, had about 30 orthopedic surgeries in my lifetime. And I had benefited from the tremendous amount of dedication and expertise of a surgeon and a few other members on his team that saw a population of kids that did not have anybody who knew how to care for their special medical needs. And he decided to dedicate his entire career to a very difficult and unique population.

And so I felt, as I was growing up, in addition to my love of science, that medicine was for me. And I wanted to be in that field. And so in order to do that, though, I knew that it might be a challenge and I might have to overcome some obstacles because I did not know anyone else who had a physical disability when I was applying to medical school, certainly not another little person like myself.

And if you looked at the stats, probably about the time that I was applying, despite the fact that 20% of our population has a disability, only point 2% of medical school graduates had disabilities. And 2% to 10% of physicians in practice had a disability. So it basically to me, as I tried to interpret those statistics, it seemed that it was pretty hard to get into medical school with a disability, maybe a little bit easier to stay in practice should you become disabled during your career.

So I knew that I was going to have some obstacles and this is where I THINK BIG motto comes in. And I’m going to share with you personal lessons of becoming a physician and essentially achieving my goals in life because I’m the girl that likes to have her cake and eat it, too. And I hope that as I go through each of these letters and more stories of how I was able to become a physician that it helps you in achieving your goals.

So, again, as I mentioned, write it down. Think of your version of THINK BIG as I go through this story. I hope it inspires you, in addition to talking about this very important discussion of disabilities in medicine.

So the first letter is T is for try. And I learned the importance of trying at a very young age. In this picture, I’m about 10. I’m having yet another surgery.

My family was extraordinarily wonderful. And they always ensured that my orthopedic surgeries, as much as possible, were in the summer so I didn’t miss school. And that meant I spent a lot of summers having surgeries and recovering in either body casts, spica casts, or leg casts, like you see here. And that was a little bit of a damper on fun in your summer as a kid growing up.

And in this particular example here, this summer, my parents kind of encouraged me to do something that I didn’t think was possible. And I had received an invitation to my best friend’s birthday party. It was at Disney World. I grew up in Florida. And I thought, well, there’s no way I can go to my best friend’s birthday because I’m recovering in a cast.

And my parents and my mother specifically said, well, why? How do you know you can’t go and have a good time? And, of course, I said it’s going to be hot. I’m going to itch in my cast like crazy. And I’m not going to be able to get up and down in any of the rides.

And my mother had this idea. She said, well, what if I send your dad with you, promise to ask him not to crack too many jokes with your friends and to make sure that you get on and off the rides OK. And if at any point you’re not having fun, he’ll take you home. So she said, just give it a try.

So in the end, I’m really glad that I did give that a try. And this is just a minor example in life of trying something that I had self-doubt in. But in the end, I had a great time. I made it the whole party.

And, in fact, as you see in this picture, it really illustrated just how hard my parents were trying to teach me to try because my dad even put me on a merry-go-round by tying my very heavy leg cast with the seatbelt to the merry-go-round so that I could ride independently by myself. And he got off and watched me. And as a parent today I thought, wow, how brave of him, because the cast was pretty heavy. And had it fallen, we would have spent the rest of the day in the ER.

So, really, I think I was very fortunate and learning this lesson early on in life of the importance of trying. And without trying, nothing is possible. And so I hope that you’ll think about in your life what’s something that maybe you’ve wanted to try, you’ve been afraid to try, or others have told you you shouldn’t do. That’s when I think you’ve got to give it a try.

So the next letter in THINK BIG and achieving my goals of becoming a physician is about having hopes. And so I like to share about having hopes. And we all have hopes and dreams. And they can be as small as that next vacation. They can be as big as that next career move or finding true love. And for me, the idea of becoming a physician was a pretty big hope for much of my life.

Well, what I want to share about the importance about having hopes for this discussion is really how important it is to have hopes when times are tough. So, again, as a person with a disability and who had gone through many medical procedures, lots of time in the hospital, this is about the age when I was about six, like you see in this picture here, when I started to realize that I was different from everybody else. That’s when I started to realize that I was a little person.

And, to be quite honest, I did not want to be a little person. And, in fact, I didn’t want really to grow up as a little person. It was a very hard time in my life.

And I think one of the things that got me through that very, very difficult time was this crazy hope that I had. And that hope was that maybe I am not really a little person. And maybe my parents had put contact lenses in my eyes so that I would see the world from a short-statured perspective and that when I was older, they were going to take out those contact lenses and tell me, oh, Jennifer, you’re really not a little person. And, essentially, I would be tall like everybody else.

Well, obviously, number one, I’m sharing with you a little bit into my psyche. And you might think I’m a little bit crazy. But second to that, I think what I’ve realized is while that hope was kind of crazy, and I am today very thankful it’s not– it wasn’t a hope that came true– I love who I am– that hope was really important through a difficult time.

And so when we think about having hopes and overcoming challenges, this is what is so important about having those hopes for your future, whether they’re professional or personal, whether they’re big or small, whether they are realistic or unrealistic, is that they get us through the tough times. And I think, particularly for individuals with different health challenges and disabilities of all types, and everybody in this audience, whether or not you have a disability, we go through tough times. And so I find it really helpful to write down your hopes, big or small, keeping them in a place that you can look to and review them when times are tough.

So let’s talk a little bit more, moving forward, about getting to that goal of becoming a physician. So, again, any goal in life, professionally or personally, you have to take the first step. And this is where I for initiate comes in.

And so I like to think about kindergarten graduation as the very first step towards getting to medical school. Of course, there were many graduations that I had to succeed in getting through before I got to medical school. But without taking that very first step, I never would have gotten to the final graduation, graduating from medical school.

And, again, everyone in this audience, to get to where they’re at, had to go through this first step. And I think what’s the lesson that I learned in thinking back through kindergarten graduation, as long ago as it was and as simple as it may seem, that very first step, while it was very far away from getting to medical school, was a necessary first step. And sometimes in life there are many things that we want to achieve. And we may be hesitant to do them because they seem so far away, like there’s so many steps to getting to them. But if we’re not willing to at least take that first step, we definitely will never get there.

So getting to medical school in any of us in our careers involves many, many steps. And, as I was in the process of preparing for college graduation and applying for medical school, that’s when I realized I might actually have hit a moment in my life where, despite trying, without having that hope, without working hard, I may not be able to make this happen.

So I, like most of my friends who were also premed– I went to college at the University of Miami. When I was applying, I submitted my application to about 40 schools. And in the first round of the application process, you get secondary applications. And so I got a high rate of secondary applications, like my friends. And then I submitted the secondary round of applications, which included a personal statement and letters of recommendation.

And in that step, I ended up putting in my personal statement, the reason why I wanted to become a physician was because I had been a patient. I had benefited so much from tremendously caring and expert caregivers in my childhood. And I wanted to give back to kids. And I love medicine. I love science.

And so, well, as I submitted my secondary step in this process, my peers were getting invitations to interview. And I was not. And, in fact, I was getting rejection letter after rejection letter from each of the institutions that I had been applying to.

Well, midway through this process, I actually went to an event at my university because I was– actually, one of the many activities that I was involved in to try and beef up my application for medical school, like we all, do was something called the President’s 100. So I was a P100, which is a small group of students. You had to apply. You had to get accepted, 100 students in the university.

And our role was to essentially be ambassadors and to host functions of the president. And this is a picture of our president at the time, Dr. Tad Foote, who was a really great president. And so I was a P100. And even though I was a little person, I guess I sort of stood out from the crowd.

So Dr. Foote knew who I was. He knew my name and always said hi to me when I was being an ambassador at one of his functions. And during the application process, he actually had known that I was applying to medical school and came up to me during one of the functions and checked in to see how I was doing.

And he said, hey, Jenny– I went by Jenny back then– he said, how is the application process going? And I said, well, it’s going. I’m hanging in there, waiting to hear from some more schools, because at this point, as I mentioned, I had been rejected from many. But I was still hearing or waiting to hear from a few others.

And he said, well, have you interviewed here yet at the University of Miami? And, as it turns out, I had already been rejected from University of Miami. And so I thought, well, what do I say? Do I tell the truth? Do I tell them I’ve been rejected? Of course, I’m not going to lie. But, I don’t know, for some reason, I felt this sense of guilt telling him that I didn’t get in. I just felt a little bit of shame there.

And so I said, well, unfortunately, Dr. Foote, I didn’t get an interview here at Miami. I said, but I’m remaining optimistic. I’m still waiting to hear from some other schools. And he said, OK. He said, well, Jenny, keep up the good work. And I’ll see you next time.

Well, about two or three days later after that event, I actually got a call in my dorm room from the Office of Admissions at the University of Miami School a School of Medicine. And they said, hello, we’d like to offer you an interview to the class of 2000. And I said, um, are you sure you have the right Jennifer Arnold? I said, I think I got a rejection letter in the mail.

And they said, no, no, no, we’ve reconsidered. We’d like to offer you an interview. At that moment, I thought, oh my goodness, I think Dr. Foote probably must have made a phone call. How else did this happen?

And I didn’t know what to say because my first gut instinct was I did not want to accept this invitation because it was really important to me to get into medical school on my own merits. I didn’t want anyone else to help me in any way. But at the same, time I thought, I don’t really have any other prospects.

So what can it hurt to interview, right? Should I really say no to this? And so I ended up graciously accepting the invitation but, obviously, being extraordinarily wary of what this really all meant. But I said thank you.

Well, it turns out after about two weeks, I did receive one other invitation out of all 40 schools that I applied to. And that was actually at my dream school, surprisingly. It was at Johns Hopkins School of Medicine. And I thought, OK, things are looking up. I have two interviews.

And so the moral of my story there is I think there are many steps to achieving those really important goals in our life. And for me, going to medical school was something I wasn’t sure if I’d be able to achieve. But I had to be willing to take that first step and keep moving forward with each step along the way, knowing that the end result may not lead to success, but if I didn’t keep taking every step and doing my best, I would never get there.

So the next letter in THINK BIG is N is for no. And what I mean by that is sometimes you have to never listen to the nos. So, as I mentioned, I had two interviews at this stage. And my first interview was actually at the University of Miami.

And I went into a room with two physicians, an internal medicine doctor and a trauma surgeon. And so I sat down with the two of them, and they started asking me what I think are probably pretty traditional questions, you know, what were my grades and what extracurricular activities did I do and why did I want to go into medicine and what fields was I interested in.

And then the trauma surgeon asked me something rather interesting. Well, he started to ask, he said, well, do you drive a car? I said, well, yes, I drive a car. He said, well, how do you do that? I said, well, I do that with pedal extensions and a seat cushion.

And he said, well, how do you plan to see patients? And I said, well, I imagine I would see patients with a step stool, like I do everything else. And then he said, well, how do you plan to crack open the chest of a 60-year-old MVA victim that comes in through the ER? And I thought, OK, well, no offense, I do think that would be challenging. I said, I don’t intend to become a trauma surgeon like him.

I said, but I do watch ER– I literally said this because I did. I said, I do watch ER. And everyone in the ER in that trauma bay is not a trauma surgeon. And there’s a lot of different roles that I think with a steps stool I could do. And I think I said to them, I really intend to go into medicine, to probably go into pediatrics or a field where my stature is not a limitation.

And so by the end of that conversation, it was a little bit of good cop, bad cop. The internal medicine doctor would say, yes, I could see that. And the trauma surgeon was sort of asking more the tough questions.

I came out of that interview pretty beet red, not sure if I was going to make it. But what I realized in that interview is that really what the trauma surgeon was getting at is that outdated belief that, unfortunately, probably still exists today, that in order to go into the field of medicine, you have to be capable of all aspects of it. And I knew that physically I had limitations. But I still believed that there was something I could do to contribute to the overall health of kids.

And so what he was looking for me to become is essentially a pluripotent or a totipotent stem cell, if you want to make that analogy. And I think it’s important that we realize that we’re going to be excluding a lot of gray individuals if we do that.

Well, I did have my second interview. So things were not looking good, I was thinking, after that first interview. I went on to the second interview. I went to up to Baltimore to Johns Hopkins.

And this time I didn’t tell anyone that I was going there because I had been a patient there up until the age of 12. My surgeon had been there. He moved to another institution. So I hadn’t been a patient there in many, many years.

But, nonetheless, I didn’t want anyone helping or hurting my cause to become a physician. So I didn’t tell anyone other than my parents, who paid the plane ticket, paid for the plane ticket. And I met with a pediatrician during my interview one on one. And he started asking me questions about my grades and my interests and my extracurricular activities, but never once asked me a question about my stature.

So I got a little nervous in a different way, thinking, oh my goodness, he’s afraid to ask me now. And so I for a brief moment thought, does he know I’m a little person? I’d better bring this up. Well, clearly he did. This is pre-Zoom. So there is no hiding it.

But I decided to bring it up. And I said, Dr. So-and-so, I imagine to see patients, I’d use a step stool. And by this point, I had thought a little bit more about some of the details of how I might operationalize my care of patients. And I told him, I said, I use a scooter for long distance. And I said, I imagine I’ll just have my double-step step stool bungee corded to my scooter so I have it at all times.

And he said, OK, that makes sense. He said, if you come here, just let us know what we can do to help you. And that was pretty much it. He showed me pictures of his kids and I went on the tour of the hospital.

So after those two interviews, to be quite honest, I was very afraid that I wasn’t going to get into medical school at either because I sort of felt neither went well but for two very disparate reasons. One was too much concern that I couldn’t do it. And the other one, maybe they just dismissed my abilities or my disabilities and were afraid to ask.

So, well, I am, obviously, here today as a physician. And I’m happy to share with you that in the end, I actually received two invitations to join the class of 2000, both to University of Miami and to Johns Hopkins School of Medicine. In the end, I chose Johns Hopkins. Not only was it my dream school, but it was the place that, based on my experience, seemed to have the least doubt in my capabilities.

And so this is, obviously, a picture of graduation. After the dean, Dean Miller left and we were all hands by our side, very formal, this is what happened. You can see I’m kind of flying in the air amongst my friends. And people are just being silly. So four of the hardest yet most rewarding years of my life.

So I hope as I share my experience of getting to that goal of mine, becoming a physician, being a member of health care, I hope you’ll think about in your life how will you never listen to the nos. And this is really important in our day-to-day work when we know it may be in the best interest of our patients or when we know it might seem impossible. But, if in our heart of hearts, we know it’s possible or we know it should be done, that’s when we have to never listen to the nos.

All right, so the last letter in THINK is K. And that’s for know, different kind of know, K-N-O-W. And I think what’s important, a lesson, or what’s an important lesson that I’ve learned in my career of practicing medicine and achieving goals, despite obstacles, is that really what it comes down to is that as a person with a disability or a person who doesn’t have a disability, it’s the individual, it’s who each of us are that knows what our limitations and our capabilities are the best, better than anyone else.

So, while you see in this picture here, I probably couldn’t be a professional baseball player, despite having fun playing in the backyard with my younger brother, I probably got a limit and am not going to be a pro sports player. I mean, maybe some sports, there are sports where maybe my stature wouldn’t be a hindrance, but probably not basketball, probably not baseball. And that’s OK because we all do have limitations.

But only each of us knows our limitations better than ourselves. And what I am capable of doing is not the same as what even another little person is capable of doing. So I think it’s important just to keep that in mind as we work and take care of patients in our daily lives.

So for me, if you think about the limitations and the capabilities, my step stool essentially is as important as my stethoscope. Without my step stool, I can’t care for patients. I ended up choosing a field, neonatology, which I love, but which really, with the step stool, I can do everything that I need to do to care for my patients.

My patients are never bigger than I am. And sometimes I think my stature and my smaller hands may even help in some respects. So we all have such great capabilities and unique features of who that we bring to the table, whether or not we have a disability.

However, as I shared with my example of trying to get into medical school, not everyone may feel the same, especially in health care. I’m so excited that we’re having this conversation today because we really need to start to understand that inclusivity and seeing the value of individuals with disabilities is a tremendous, tremendous benefit to health care. And I’ll share a story with you that even happened more recently.

So while getting into medical school was definitely a challenge, once I got there, I felt like I was very well supported during my residency and my fellowship. I mean, the institution worked with me, found out what I needed from my perspective. We obtained step stools for all the rooms. It was no big deal. In fact, the patients sometimes liked to use them.

We put lower hand sanitizers and just minor modifications, really, in the grand scheme of things. But it allowed to be completely independent and completely successful in my work. And so, ironically, as I more recently in a recent institution that I was working in, still continue to face challenges with acceptance and accommodations.

I was looking to be credentialed at a neighboring hospital where my neonatology department provided neonatal care for babies when they’re born in the delivery room. And so I was going through the credentialing process of this hospital. I was, essentially, I got credentialed, no problem, assigned my first couple of shifts.

And before my first assignment, I said to my department head that, oh wait, I can’t forget to get step stools placed in the delivery room before I take my first shift because, otherwise, I’m not going to be very effective. And so they said, OK, let us look into that. And then they wrote back to me and they said– and this is 2020– they said, “Jennifer, I’m so sorry. It looks like we’re not going to be able to move forward because the institution is unwilling and unable to purchase and/or maintain step stools in the delivery room when they have other neonatologists that are capable of providing the same service.”

So and I have this in an email. So not only did they tell me this, they wrote it down. I thought, this is really unbelievable in this day and age. I felt like I understood getting into medical school and all those challenges. But I thought, today, still? And after I’ve already been practicing as a clinician, this is going to come up?

And it does. And it did. And I think what was hardest about that situation is that I learned or I feared not for myself– I mean, I’m now farther along in my career, comfortable speaking up for what I needed. But I was petrified for the new learners that would come in and be told the same thing and then not get delivery room experience and miss out on important aspects of their education because they may be afraid to speak up, maybe not, but they may be. I know when I was at a training level, I probably would have been.

And so, obviously, I spoke up. And, in the end, they ended up fixing the problem. And it never got to the point to where I had to do anything more aggressive with legal action. But even just the fact that that happened to me in my own institution was very disheartening and made me feel a sense of a lack of support, even in my own organization.

So one of the things that, lessons that I’ve learned is that we all have limitations, no matter whether or not we have a disability. But we all have amazing capabilities and assets that we bring to the table in the care of patients. And so I learned this lesson probably the most from my surgeon. So I wanted to share a picture of him, the one that I had mentioned that inspired me to go into medicine.

This is Dr. Steven Kopits. And he was really what I would consider a servant health-care clinician. He cared deeply about all of his patients.

And when I graduated from college and I was entering into medical school, he shared with me some advice. He said, no matter how well-trained, intelligent, or well-intended you are, Jennifer, remember, you’re going to encounter patients you cannot save, puzzles you cannot solve, and problems you cannot fix. And I think what he was trying to convey to me is that as we go into the field of health care, we have to remain humble. We have to not be afraid to seek help when we have our limits and recognize them, but to also to be strong and determined in our capabilities.

So I think it’s that balance that sometimes is hard. But I think all of us, if we can find and think about ways that we can not be afraid to share our limits and our capabilities, then we are going to be the most successful health-care clinicians that we can. So that’s where knowing comes in.

I’m going to wrap up the THINK BIG with BIG. And I’m going to kind of move a little bit off of the medical path and into the personal path because I hope that sharing my story inspires all of us not only in our professional work, but in our personal work. And this is where B is for belief comes in.

And so some things in life, no matter how hard we try or work or hope for, we can’t make happen. And I sort of think finding true love is one of them. But as a person with a disability, I knew that I had to continue to get out there. And I needed to continue to have belief that maybe it was possible.

But I had a lot of self-doubt, as many of us do, and particularly those, sure, with disabilities, like myself. I thought to myself, who in their right mind would want to dance on their wedding dance on their knees with their spouse, right? That was the negative thought that kept coming in my mind as I thought, I’ll probably never find true love.

Well, I got out there. As you can see in this picture, I got on the dance floor. I went to every dance, just keeping up that belief that one day it would happen, maybe, despite my trepidations or my negative thoughts.

And I’m glad I kept believing because at one point, I finally decided to take a step proactively. And I got on a dating site. There is a dating site for everyone, I think, today, which is great. If there’s not, we should create one for everyone.

And I searched with my best friend, who went on Match.com, who she doesn’t have a disability. And she was also single, like me, and hanging in there for belief. And she was looking 50 miles around Pittsburgh. I was looking 500 miles around Pittsburgh.

And we said, we’re both going to write to one person tonight. And we both did. And, well, my criteria were pretty basic. They just needed to be not married, looking for love, and have a job. And that was pretty much it for me.

And I found one profile of this young man who was pretty handsome looking. And his name was Bill Klein. Well, it turns out that this person that I shot a random email to was actually someone who, growing up, we had met in the hospital as kids at the age of 10. We both had gone to the same surgeon growing up for our surgical needs.

And our surgeon had tried to set us up 10 years later when we were in our 20s because at one point, Bill thought he was going to go to medical school and did not. Smart guy. He went into the business side of things. And then we actually met another 10 years later in our 30s online.

And so, of course, when I first met him and he revealed to me after a month or two of emailing and phone conversations that he actually knew who I was, I feared that I had met my first stalker. Go figure. Here we go. It turns out, though, that after he revealed to me that he’s known me since we were kids, I reached out to our surgeon’s nurse practitioner. And she reassured me that he was the one she tried to set me up with and that he was a pretty good guy and kind of passed the background check.

So the rest is history. And what I hope that sharing my story shares with you or means for you is that, again, whether or not we have a disability, there are things that we can’t make happen, no matter how hard we try. And those are the things that we have to keep believing in, hanging in for, even when those results may not be immediate. If they’re well worth waiting for, I do believe it will happen.

So the next letter in BIG is improve. And I is for improve. And so I think what’s really important here is whenever we achieve a goal, whether it’s personal, like finding true love, or professional, achieving that career goal that we want, it’s important that we not just sit back and relax and say, OK, I’m done. I did it, right?

No, life is about lifelong learning and lifelong improvement. And that’s what I love about what I do now professionally with simulation because it’s all about constant improvement for all of us as health care clinicians, but whether it’s being a parent, a spouse, a health care giver, we have to constantly improve. And it’s hard every day when our systems are so complex. We are so busy. There’s not enough time.

But even the work that we’re doing today is about improving and making the world a better place. And the more we can take time out to improve, the more resilient we are going to be, our teams are going to be, and our health-care systems are going to be. So I hope that each of you will think about your constant need or your constant opportunity, I should say, to improve.

So I’m going to wrap up hopefully on a positive note here. I’ve shared with you overcoming obstacles, but knowing that we all have limitations and we continue to have to face bias and misconceptions about what our abilities are, particularly those of us who have disabilities. But I think sometimes when there are goals that we have in life. Some things we may not want to wait for. We may just want to throw caution to the wind.

And that’s where going for it comes in because I do think that truly, life is short, no pun intended. And we never know what is going to happen tomorrow. So while becoming a physician for me was definitely one of those goals, that I needed to have grit and perseverance to keep going, many steps to getting there, long term, those goals, don’t get rid of them. Keep going for it.

But then some goals we may just be putting off because we think we don’t have time or maybe we’re afraid or others are telling us no, we shouldn’t, or we can’t. And I can’t tell you the number of people that told me I shouldn’t become a doctor– too physically demanding, how would I be able to do it? But if in your heart of heart it’s something that’s important to you, that’s when you got to just go for it.

I’d like to think that I learned that lesson through my recent cancer journey because at that time in my life, as an individual, I sort of thought, OK, being a little person, having all these surgeries, isn’t that enough for one person, right, to have to overcome? Well, I never expected to get cancer is, I guess, what I’m saying. I don’t think anyone ever expects something like this to happen to them.

But it happened at a time when my life was really wonderful, almost perfect. I had a great career. I was living in Houston, I was married to a tremendously amazing spouse. I had two kids. I had just become a parent to two children, who I internationally adopted and adored. And I felt like, check, check, check, life is good, right?

And that’s when sometimes, when you least expect it, something comes at you out of left field. And that’s when I was diagnosed with cancer. Well, I think while that journey, my cancer journey– I’m not going to spend time talking about it– was in and of itself a challenge and a journey, I, in the end, am thankful that I am completely cured.

And the lesson that I learned from that is that we really do need to continue to go for the things that are important in life, whether it’s something as small is going for that next trip to the ice cream parlor with your kids or something as big as taking that next step towards what’s important to you in advocating for others, making a difference in your community, maybe making a difference in your own life or your goals and dreams. We definitely just need to go for it. Today is your day. Don’t delay.

And with that, I hope that my opening talk helped to set the stage for a really exciting discussion today, sharing my personal story of getting into medicine and just all the things that I’ve learned as a person with a disability. Thank you so much.

LORI NEWMAN: Thank you so much, Jennifer. That was truly inspirational. And it’s a real privilege to be able to work with you and get to know you better. So thank you.

JENNIFER ARNOLD: Thank you.

LORI NEWMAN: Now I’m going to invite Bonnie Crume to speak to us about her experiences being a resident and fellow at Boston Children’s Hospital. So, Bonnie, if you want to come on. And, Joey, maybe you can put the spotlight on?

BONNIE CRUME: Yeah. No problem. Sorry. I’m getting over a cold. So I apologize. My voice is a little weak.

But thank you, Lori. And thank you, Dr. Arnold, for sharing your story. I’m in awe of everything that you have accomplished in your life.

And good afternoon to the academy members. It looks like there’s a few familiar faces in the Zoom Audience. So hello.

But for those of you who I haven’t met, as Lori said, I’ve really primarily been invited to share a glimpse into my experience navigating accommodations here at Boston Children’s. So I have considered a hidden disability, a congenital bilateral and sensorineural deafness. And I wear hearing aids to help access sound. But I communicate primarily by spoken language and by lip reading. And, on occasion, I use some adaptive equipment and technology as needed.

I first established what kind of accommodations I would need through trial and error in medical school. That’s when I learned about the clear masks to accommodate lip reading, about amplified stethoscope to help me hear, some Bluetooth-compatible microphone systems with hearing aids, and different transcription services.

So once I began training here in 2018 as an intern, I completed a Reasonable Accommodations Request Form, outlined all of those things that I learned in medical school, and easily approved by Occupational Health. And I was ready to begin. I thought the hard part was over. I got through Med school. I figured out what I needed.

But I quickly learned that the transition from being a medical student to a clinician on the ward, it’s different. There were new possibility that require different accommodation that I hadn’t previously considered. The prime example I’ll go through today is the use of a telephone.

The phone has always been a major roadblock for me. And that is because I can’t use lip reading to help discriminate speech. And phone calls aren’t captioned.

And as a medical student, I was not required to speak on the phone. And I could communicate by having face-to-face conversations. And, unfortunately, in a very large hospital, like Boston Children, with a very high consult burden, it’s really hard to avoid talking on the phone. And when we first started, when I first started here in 2018, we were using those Ascom phones, the retro, indestructible phone that did not have any texting features, unlike the current SpectraLink system. So it really felt like I was stuck.

At that point, I wasn’t sure the best route to go about modifying accommodations. I brought these concerns up to my team, the chief and the leadership. And they were very enthusiastic to help. But we just couldn’t quite figure out a system that worked. So I just tried to manage.

And I watched my colleagues, my cointerns, and residents than take phone calls with no effort. And they would even do two phone calls at once, which I found absolutely mind blowing. Something that was so easy to them was impossible for me.

But I just figured it out. I would run and find a quiet place if I could to have a phone call. It would take more time and effort. Quiet places don’t exist anywhere, especially in the emergency room. Or I would just go find the signers and/or the consult, consultant, and have a conversation with them in person and was at least getting by.

Then COVID came along. And with the institution of a mask polity, I could no longer read lips. I couldn’t bypass the phone call by having a face-to-face conversation. And we also needed a system to rapidly disseminate clear masks, which, of course, were on back order.

At this point, I was very overwhelmed. I was, like everyone else, I was scared of the pandemic itself. But I was also scared that I wouldn’t be able to continue my training, something I had worked for for a very long time, all because of inadequate accommodations.

As if residency itself wasn’t challenging enough, my burnout accelerated. On one hand, I was too scared to admit how much I was struggling with it, despite having a supportive team, because I didn’t want to feel or come off as incompetent. My residency team was willing to do whatever was necessary. But they didn’t have a knowledge of the nuances of my disability. And I felt really misunderstood in our discussion about what they considered to be reasonable accommodations.

On the other hand, I didn’t want to spend what little free time I had outside of work thinking about creative strategies to overcome these barriers because I was exhausted. But, ultimately, through additional research and perseverance, we finally found a system that worked about two and a half years into my training.

In retrospect, there were several key points that I took away from the journey that I hope I can share with you. First, I learned that disability accommodations often falls on the learner, even at one of the most well-resourced children’s hospitals in the country and even with a very supportive team. And each individual is going to have a different way that they adapt. So it’s not as simple as a one-size-fits-all accommodation for a given disability.

Another important lesson were the accommodation change, especially as technology advances and we have a new phone system being rolled out or pandemics apparently occur and that can cause mask mandates or virtual platforms, such as Zoom. And those can introduce new barriers. So accommodations should really be reviewed on somewhat of a regular basis, to say, how do we change it, and quickly adapt, if needed.

I do believe it’s important to have a diverse and inclusive health workforce. However, even with the best environment and the best intention, it can be really tough to do. But hopefully with academy sessions, like today, and raising awareness, advocacy can become a team effort to help streamline accommodations in the workplace.

So now Lori will introduce, kind of preview the proper process of picking accommodations here at Boston Children’s. Thank you.

SPEAKER 1: Thank you, Bonnie. So, Joe, if you want to spotlight me, I’m just going to share my screen. And give me a moment. Can you all see my screen? Is that a yes? Yes. OK.

All right, so now I’m going to review requests for accommodations at Boston Children’s Hospital. I did a lot of investigation and research to figure out how I can clearly present this to you. I know you still will have questions. And we will, of course, take questions at the end of our session.

So, first of all, I want to let you know that an accommodation is– a request for accommodation is a statement that an individual needs a work or education-related adjustment or change for a reason related to a disability. So at Boston Children’s Hospital, we need to think of our learners in three different groups. So you know that the academy is dedicated to enhancing teaching and educational scholarship for all of our learners.

So there’s three different groups of learners that the hospital sees. And, first of all, there are professional school students. So these are our nursing students, medical students, PT students, social work students, psychology students, et cetera. And all professional school students must work with their school’s disabilities office to request accommodations. And it is the student’s responsibility to ensure that any modifications that are determined by their disabilities office are communicated to their BCH program or clerkship director or training director.

Next, we have employees who are paid by Boston Children’s Hospital. These are people who receive a check, a paycheck that says Boston Children’s on this. And this includes all residents and trainees. So these individuals must submit their request for accommodations along with documentation from their treating provider to Occupational Health Services for their review. And then a discussion will ensue with the employee’s supervisor about which accommodations the hospital deems as reasonable modifications to their learning and work environment.

Our third category are individuals who work for one of the many hospital’s foundations. And so these are many of our attendings. Individuals who work for a hospital foundation are not considered BCH employees. And for their accommodations, they should speak to their foundation’s HR administrator about the process for accommodations. OK. Just a second.

All right, so now I want to present two scenarios regarding policies and processes here at Boston Children’s Hospital that you, as an educator, may face. So if an employee informs their direct supervisor, their division chief, the program director, their direct manager that they have a disability requiring a work modification, the supervisor should immediately direct that individual to occupational health to start the accommodation process. That supervisor program director may not ask about any private health information. So that is the first step.

But then our hospital is very active. And there is a second scenario that is likely to occur. So if you find yourself that you are the supervisor/preceptor/attending of the day on a service or a rotation or on the floor or an ambulatory clinic and you’re just the supervisor that day and an individual who you’re just meeting for the first time and you might know today but not tomorrow discloses that they have a disability and need modification to perform that day’s work, you should first ask if they already have an agreed-upon accommodation from Occupational Health. Hopefully they will say yes and then have a plan that you can put into practice.

However, if they say no, you as that supervisor/preceptor/attending must engage in what is called the interactive process and discuss with the individual what suggestions they have that will allow them to participate as best as they can in that day’s work or educational activities. You may not send them home. You must engage in a discussion.

So you, after having this discussion, you must advise the learner, however, that they have to reach out to Occupational Health to submit the required documentation. You should also send an email to that learner documenting the discussion that you had, including the instructions to speak with Occupational Health. And I would advise you to CC Occupational Health. So here is the Occupational Health’s email and their phone number.

Finally, I want to let you know that at this time, Occupational Health Services processes accommodations, but they do not have the expertise or a disability service specialist who can offer advice on how to implement accommodations. Occupational Health expects individuals to work out solutions with their department chairs or program directors or training program directors and then inform Occupational Health of those modifications.

Again, I’m sure you have a number of questions. We will be having a Q&A towards the end of this session. It is 1:09. And we thought before we engage in our interactive breakout sessions and then have a wonderful keynote address by Lisa, we would have a 10-minute break.

So please stretch, get some food, get some water, take a break, turn your cameras off. And meet us back here at 1:20 for the second half of our retreat. All right, thank you. See you soon.

OK, it’s 1:20. Welcome back, everyone. I hope that was a good break. I am now going to turn this over to Lisa. So she can introduce our breakout room activities.

LISA MEEKS: Thank you, Lori. And, I must say, I’m floored that you have been on time. Everything has run so smoothly. That never happens. And what a testament to your planning. So thank you so much for all the hard work.

I do want to take an opportunity before I introduce these characters to say a few things about the speakers that just presented. And I think I just want to get everyone in an a frame of mind and have these two ideas in front of mind before we go into these breakout sessions. One is think honestly and do some honest reflection about whether you would have welcomed Dr. Arnold into your training program prior to having seen how successful she has been. And you can imagine the barriers that were there for her.

And that was– she graduated in 2000. And it was, as I was sitting, listening to Doctor– and is is Crum, Chrome? I don’t want to mispronounce.

BONNIE CRUME: Crume.

LISA MEEKS: Crume. Crume. OK, so neither of those. Crume. As I was listening to Dr. Crume, first of all, my heart just ached for her and having to– and then listening to Lori. And I get that this is the system that we operate in.

But having people have to come to the table with all of the solutions when they’ve never been in these situations before, they’ve never been in our clinical space before, they may not have ever engaged in accommodations before, and having the burden or the tax, as we so often refer to it when we’re talking about other groups, it’s a part-time job. And it also, I think, amplifies the shame that many people bring to that space, even needing to ask for something.

So as I was listening to these two experiences, one of the things that was so difficult for me, since this is my life’s work, is thinking about the fact that from 2000 to 2023, it doesn’t appear that, even though we have lots of publications, we have lots of guidance, we have lots of support from medical organizations, that we’re making much progress when it comes to the daily interactions with learners. And so I really want you to think about these two experiences. And we’ll talk a little bit. We’re going to name it.

I’m going to bring you the very applied, direct information today. And we’re going to name it. And we’re going to talk about how it impacts everything we do.

But first, I want to introduce you to our trainees. So we have Noa. You will go into breakout rooms, by the way. There’ll be four breakout rooms. You will automatically be put into a breakout room.

And then you’ll have a discussion guided by the prompt that you see here. Noa is a learner in your program with a learning disability. Noa comes from an Asian background culture, identifies as genderqueer, and uses they/the/their pronouns.

They’re getting ready to enter the clinical portion of your training program. What concerns do you have about Noa and the potential barriers they may face in the clinical setting. So Noa is vignette or however you want to conceptualize it number one.

Molly– Molly is a learner with– and, by the way, all of these are based on real people that I’ve worked with throughout my career. Molly is a learner with a physical disability who uses a wheelchair. She’s been disabled since childhood and is a paraplegic.

Molly comes from a socioeconomically disadvantaged background and uses she/her/hers pronouns. Molly is a candidate applicant for your program. And, as a clinical supervisor, you are asked to weigh in on potential barriers or concerns in the clinical setting.

Michael has a psychological disability, identifies as Black and first generation to college. Michael had to take a leave of absence in his first year after failing a course and having a flare of his symptoms. He has struggled but passed all of his courses.

Michael meets with his mental health counselor one time a week and uses he/him/his pronouns. He’s getting ready to enter the clinical portion of your department’s training program. What are the potential barriers or concerns that you may have about Michael in the clinical setting?

And, finally, Zola– Zola, she/her/hers is a fellow in your department and has epilepsy brought on by stress and exhaustion. She’s getting ready to start her first clinical service next week. What concerns do you have about Zola and potential barriers she may face on service?

So now I think Joe’s going to do the honor of transporting us into a breakout room to discuss for 15 minutes. And please make space and take space equally to discuss the potential or perceived barriers. And then we’ll come back together as a group.

Thanks, Joe. This is like Jetsons level stuff, right, for those of us that– I just gave my age away. Saturday morning cartoons–

[INTERPOSING VOICES]

LORI NEWMAN: I watched them, too. I watched them, too. So Joey has just put into the chat a URL which includes the breakout group directions. As Lisa said, each of you will be put in a breakout group room. In the directions, you’ll see the case that you’ve been assigned to and your facilitator.

And when you get in the breakout room, just please give your facilitator a minute or two to set up the Zoom whiteboard, read the case together. And then I did want to let you know that Lisa has done a wonderful job that the students or trainees or learners that are in the case could come from any profession. So when you’re thinking of the situation, think of this learner in your own clinical setting. And yes, all of this information has been disclosed to you.

So now I think we are ready to go. And Lisa will be popping in to help us. I think we’ll just go breakout room one, two, three, and four. And the facilitator will show the whiteboard and give a quick summary, summarize as best as possible. Yes, things got a little messy in our room. That’s OK.

LISA MEEKS: And then I have some high-level summaries from going in and out of the rooms that we’ll cover. Perfect. So breakout room number one?

LORI NEWMAN: Yeah, Alan?

ALAN LEICHTNER: Can you all see my screen?

LORI NEWMAN: Yes.

ALAN LEICHTNER: OK. We actually had two pages. I didn’t have time in the one-minute transition to save the other page. So you’re just getting page number one. And we had some problems with getting everybody on board that they could find the text and then this unexpected problem that people would be writing over each other, which has been difficult.

So Noa has a learning disability. And she has some other aspects– her Asian background, identification as genderqueer, and use of they/them/theirs proteins. So a lot of people were worried about being able to trust Noa as a teammate.

I think the comment in black at the bottom left is helpful because there may be concerns of reading next– needing extra time to process during rounds, documenting, doing other things that require calculations, and that there may be a need for more time. As Greg said to us, one of the core values of our hospital is being able to do stuff urgently. And so we’re judged by our peers in the ability to keep up and do the things urgently.

So I think those are the major things that came up. People also worried about acceptance by patients and parents and families. So I think that’s it. Lisa, back to you to comment. You’re muted, Lisa.

LISA MEEKS: Sorry. I’ll comment at the end after we go through all of the cases. Yep.

ALAN LEICHTNER: OK. Then I’ll stop sharing my screen.

LISA MEEKS: So case number two?

SPEAKER 2: Hi. All right. Can you guys all see my screen OK?

LORI NEWMAN: Yes.

SPEAKER 2: All right, perfect. All right, so we discussed Molly in our breakout room, who is a learner with a physical disability who has been disabled since childhood and uses a wheelchair and has function of her hands. So if I could summarize the discussion, we had a lot of PTs and OTs in our group. So we were a little concerned that Molly might not be able to physically handle the requirements of the job, to be able to safely handle and manage the children in the capacity that she might need to and also be safe herself.

There was a lot of discussion around safety in navigating the physical environment. We talked about, although we are technically accessible, there might be some challenges. One person described the ED and the challenges that can occur there with the volumes of patients coming in. And we talked a bit in PT about our high-volume times. When things get [AUDIO OUT] and we’re using every inch of space we can in the department, might have some difficulty navigating that environment safely?

We talked about from an emotional or psychological safety vantage point, would we have the skills and ability to be able to meet her needs? Or would we need supports for that as well? And although we discussed that the onus of responsibility should not be on the learner to design accommodations, we wondered, would it need to be bidirectional, that we would have a better understanding of what Molly’s needs were within our space from a clinical perspective? I think that kind of sums things up. Stop share now, Lori.

LORI NEWMAN: Yes, you can stop sharing. Yes. All right. Sorry. All right, now I’m going to share my screen. Hold on.

OK, can you see that? Yes. OK, so we had Michael, who has a psychological disability and identifies as Black and is first generation to attend college. Michael had to take a leave of absence in his first year after failing a course due to having a flare-up of symptoms. He struggled but passed all those courses. And Michael meets with his mental health counselor one time a week and uses he he/him/his pronouns. And he’s getting ready to enter the clinical portion of his training.

So things that we discussed were, for example, first of all, we weren’t sure how his peers might react because say one of the accommodations might be that he needs to take some extra time when things get stressed. And we were wondering how– there’s real peer pressure here at Boston Children’s Hospital to be excellent, to be excellent at everything that you do. And people might wonder why he might get less of a patient load and why they don’t get that, and knowing that by law, he doesn’t have to disclose this disability, and nor can the supervisor to anyone else unless he says that’s OK.

We talked about what if something triggers Michael during a patient encounter? Would that cause some patient safety issues? We talked about if he needed to take off some time because of his psychological disability, how the pressure that would be on him and the supervisor to get him caught up to his peers so that he has learned everything that he might have missed when he had to take some time off and just how his psychological disability might impact the other learners in the group.

So I think it’s messy. But that pretty much summarizes a lot of our discussion. So I’m going to stop sharing. And Eva?

EVA GOMEZ: Yes. So to recap our case, Zola is a learner in the department that has epilepsy brought on by stress and exhaustion. She’s getting ready to start her first clinical rotation and the concerns that we had.

So I created a whiteboard. And I am trying to figure out– I don’t know that– it did not. So I tried saving it. I’m going to stop sharing for one second. That’s OK. I took extensive notes so that I can share with you because for some reason yesterday this worked and today it didn’t.

OK, so for Zola, the first thing that came out of the gate was the fast environment. We are in a fast environment. People need to respond quickly. And for somebody who has this type of disability, it can be challenging because the expectation, as many of you have already said, is that you need to be able to keep up with all that’s going on, right?

Other concerns that came about, the stigma that comes with knowing or disclosing this disability and how the learner may experience discrimination. And also through this concern, too, is that the person may themselves experience a lot more stress about being deemed as not capable of doing this type of work. We discussed a lot about because this is a medical condition, it could be a little bit of a gray area, how much it is disclosed to others.

Somebody expressed the situation where they actually had encountered this in real life. And there were concerns around the staff safety, whether there could be a problem for staff or also the patient safety. And when we talk about patient safety more deeply, we think about what is going to happen if– what happens if this person has a seizure in the middle of their work, right? Is the patient safety compromised due to the episode actually happening? And also the discomfort of coworkers, feeling that there’s a concern but being afraid to speak up to their supervisor, yet having an internal sense that this could be a patient safety concern for patients, right?

Other things that came up were the concern about the assumptions of others as to what can a person really handle? So, for instance, there’s a person who’s working in the environment with this learner. And they may have their own assumptions of what’s right for them versus asking the person directly what is right for them and what can they handle, right?

Another concern that we talked about was the psychological safety and that negative psychological effects on the person, especially if they may even experience a little bit of imposter syndrome, where they feel that they may not be adequate or feeling comfortable in that environment.

And, last but not least, well-being and burnout, that there’s concern for the person who constantly has to worry about their experience of disability and not being able to function in their environment and how that becomes sort of an ongoing internal struggle in having to navigate and get through the day. So apologize for the screen not sharing. But I hope I was able to capture everything that we said in our group.

LISA MEEKS: Great. Thank you so much. All right. Any other comments?

ALAN LEICHTNER: Lisa, one of the things that came up in our group that I would love for you to address is who should learn about the disability. If it’s a hidden one, should we tell all the other people on the team? Should we pass it on to the next supervisor, that sort of thing?

LISA MEEKS: Perfect. Yes. I was there when that question was asked. And I was thinking, I don’t remember who asked the question, but I would love for that to get brought up again in Q&A. I do want to make sure you have some sort of writing device because you’re going to start having lots of questions as we go through these things.

If you’re like me with age, my brain doesn’t work quite as efficiently. So I’m constantly having to write things down to remember them. But your questions are important.

The other thing that I want to say is I’m just really thankful to all of you for the honesty and the vulnerability you brought into that space. I noticed a lot of people talking, even though you had the ability to anonymously write on the board, you were engaging in a conversation really honestly. And I appreciate that because that’s the only way that we can learn, is to be honest about what we’re feeling, what we’re thinking, right?

So I’m going to share my screen again. And I just want to say one thing before I start talking because if I start talking too much and I don’t say this, all of you are going to have this very strong reaction because we’ve all been taught to use what’s called person-first language. So just a little note about language from the disability community, there are two schools of thought about the types of language that’s used. There is person-first, which is likely what you were taught, which is a person with, right– a person with a psychological disability, a person with a learning disability, a person that is deaf or hard of hearing.

But there’s another, on the flip side of that, another group of disability advocates and individuals with disabilities who say, you know what? My disability is salient in who I am. It is a core part of what makes me me. I have a lot of disability pride.

Therefore, I choose to use identity-first language, which would be deaf. I’m a deaf person. It would be, I am a disabled person. A lot of the difference you would see is the switch between talking about disabled trainees and trainees with disabilities.

Now, where I get the most pushback on this is from reviewers, actually, because the AMA and other organizations have said very clearly that you are to follow person-first language. But I think that’s really unfortunate because it loses an element of pride in identity that is held by many people with disability. And what’s most important to me, as a person who just loves humanity, is that people should be able to identify in whatever way they are comfortable identifying. And that cuts across all, whether it’s gender or sexual identity or disability, people should be able to identify in the way that is most comfortable for them.

Now, I choose to, as a way of honoring both of these groups, I choose to vacillate my language and move between person-first and identity-first language. So you will hear me say disabled trainee today, disabled learner. You have also seen on the slide some says disabled, some says person with. So I go back and forth.

And so I just wanted to put this out there, one, because I don’t want you to be uncomfortable in this conversation with the use of my language. I want you to have a way to ground it and understand it and, therefore, hopefully not be offended by the differing uses of language. But two, I want to remind everyone that in any way that we put a label on someone or we put an identity or we put any type of restriction on someone, that’s one way of a group controlling another group. And so I hope that none of us do that.

I always kind of laugh and say you should call people by their name. I think that’s the most appropriate thing to do. And you likely will not need to refer to anyone as disabled or a person with a disability. But when we’re talking about it in the academic sense, I go back and forth. So hopefully that makes sense.

The other thing that I want to go over with you is– oh, and I’m going to just hit Escape so I can really quickly grab my notes. And I’m actually happy to share these notes with you. So while I was going in and out of your rooms, I was taking some notes and rolling some things up. So here are my little notes. And then here are the way that they rolled up.

So my thoughts my reflections on what I heard today, First Of all, I heard what I expected to hear. So there was nothing abnormal about your response to these cases. In fact, these cases prompt very similar discussions.

The only thing that I heard that was new today was this idea of trust. And so I really need to think about that. And I would love for us to talk about that a little bit more.

But a few points– first of all, there was a discussion about do we know who knows? What do we know? To what extent do we know?

The reality is people with disabilities are all around you. I wish I could give you a research talk in advance of this because there is so much to– I think we published something like 40 papers in the last year and a half. There’s so much to tell you.

But the reality is people with disabilities are in your programs now. So if you’re thinking you don’t have people with disabilities, that’s wrong. You do. They’re not telling you that they have disabilities. And we’ll talk a lot about why that is.

And people with disabilities have been in your programs for years, really. And they have just adapted to the program and made the best use of the situation, oftentimes without accommodation.

Safety came up as a theme, and as well it should. Were all in health professions programs. And so we do want to create a safe environment. Safety issues and safety fail safes and checks and balances systems were implemented because lots of people have made errors, including people with disabilities and including people without disabilities, over the years. Every time a major medical error happens or occurs, we do an evaluation, like a root cause analysis, to find out where in the system something went wrong and how we can improve it.

Therefore, safety is a universal issue. And we would expect on the kind of developmental continuum and into training, we expect that all learners and trainees will have errors. Admittedly, my work is very grounded in medical education. But the majority of first-year interns make major medical errors as they’re starting to develop their skills and as they’re transitioning into becoming a licensed physician.

And we know this. And it leads to jokes like don’t go to the hospital in July of every year, right? If you have an intern, ask for the attending. These are meant to be jokes, but they’re grounded in the fears, the natural fear that comes with a new learner in any situation under any circumstances.

Knowing someone is disabled, we really wouldn’t know that. Depending on your role with that learner, you may not know that unless you’re implementing accommodations. And I think as well, you shouldn’t know that. That’s a part of someone’s identity that if all barriers are addressed with accommodation, then that person, therefore, has access to all of the learning environment tools, all of the clinical tools, everything that they need. There’s no need to discuss their status as a person with a disability, just like there’s no need to discuss their status as a part of their sexual identity or their race or ethnicity.

In fact, I would, as kind of a checks and balances, oftentimes people will say something to me and I’ll say, well, I want you to take disability out and put– choose any underrepresented racial or ethnic group in medicine writ large, right, so whether it’s nursing, OT, PT. I want you to substitute the word disability for that race or ethnicity and think about whether or not what you’re saying is appropriate in that context. And if it’s not, it’s almost assuredly not appropriate in the context of disability. So just a way to kind of do your own checks and balances.

Time came up as a theme, which didn’t surprise me at all. I fully expected this. And what I would say is that human performance is on a time continuum, right? Perfect example, if I complete a specific surgical skill, right, in a simulation lab, because I’m not a surgeon, so we don’t want me doing this anywhere else.

But I’ll get in the sim lab. And we do a lot of playing around for disability-related reasons. And I’ll do a specific procedural skill.

I shattered my left wrist. I can no longer do it as well as I would have been able to do it four years ago. Moreover, at this point, I’m 52 years old. I can’t perform or do a procedural skills with the same speed that I would have been able to do it at 25, nor is really the majority of our providers.

So when we think about the time that it takes to do something, we need to be thinking about time in the sense of a range of time that it would take somebody versus a static point in time. And we’re all always comparing or worrying about people with disabilities compared to this nebulous need for immediacy. Time, you’re under time pressure. But we don’t qualify that.

And when determining whether an accommodation is reasonable or determining if somebody is not eligible for your program, you need to be able to not only qualify something, but quantify it. So what is the space and time that you have to be able to do a procedural skill or to respond to an emergency, that sort of thing? And then once you’ve done that, then we can talk about time and the need for time specifically.

Downstream exams or licensing came up. And this was such a good one because I do think that while preceptors may not be concerned about this or instructors, I do think program directors or whatever they’re titled in your respective specialty, I do think that they worry a lot. If I accept this learner and they have a learning disability, are they going to pass Step 3? Are they going to be able to be licensed? That’s a legitimate concern.

What I can say is that in my research, we have shown time and time again that previous testing is a predictor of future testing across from, at least in medicine, from MCAT through the step series. So there’s a positive correlate there. And we’re able to say that if someone’s coming into, let’s say, a medical education program and their MCAT is– you can actually take their MCAT, it’s really kind of interesting, and predict what their Step 1 and Step 2 scores will be. So we have a mechanism of prediction. But while I do think that is a serious concern, I don’t think it should keep someone from accepting a learner who’s performed well because past performance is predictive of future performance.

As far as licensing, that’s almost always around mental-health-related issues. And I would say that is a serious concern. Depending on what your program does and the trainees that you work with, you have a fiduciary duty to report to state boards and perhaps national boards. So that is something to consider. That is a conversation that we often have with students with psychological disabilities who have to go out because of an emergent need.

Space came up. And I actually tried to pull this data. I don’t have the exact data, but I tried to pull it down because I like using this as an example. So space came up. And it was almost like somebody wrote this question for me because it was space related to emergency room navigation. And I would say emergency or ED navigation is difficult for everyone.

But the foot space or kind of space that a wheelchair takes up is about 26 to 30 inches. And I’m in Chicago. So we have very large men. So if you think of a larger man and the footprint that they will have waist side left to waist side right, it could very well be 26 to 30 inches.

So in many cases– and I have this slide– I should have pulled it had I known this was going to come up– where you see the space of a wheelchair and you see the space of an average 6 foot 2 man in Chicago and you think, OK, that argument doesn’t really hold a lot unless every provider in the emergency room is a tiny little person with barely any footprint. Moreover, I can name easily on one hand and would have to go back and get the names on the other emergency room physicians that are also wheelchair users. So while space is terrible for everyone, there are easy ways to navigate that space and the patient rooms as well. And I’m writing up lots of case studies with different groups across the nation on these types of implementations to help reduce the assumption that it’s not possible or that it’s going to be a considerable amount of work.

Can we meet their needs? So one of the things that came up that I always expect to come up is someone to say, how do we know if we can meet their needs if they have a learning disability? And to that, I would say, how do you know what their needs are?

This is really based in assumption. We do a lot of assuming that a person with a disability is going to have a considerable amount of needs. The research actually shows that especially for people with physical and sensory disabilities, they have very little needs. Once an accessible workstation is employed or a team of interpreters is employed or captioning is employed, they have very, very little needs.

And so the reality is that, yes, this has been done across the nation. There are also multiple court cases that say that this is reasonable. So not only are the courts saying it’s reasonable, but it has been done repeatedly unsuccessfully.

And, by the way, that particular group, deaf and hard of hearing and physical disabilities, have the same outcomes on performance. So their scores are the same. They match the same. They are employed at the same rate. So there shouldn’t be any concerns about that particular group.

Time off, I heard a lot of discussion about time off related to our learner that had a psychological disability. And I think that’s valid. But I want us to think about the time off that everyone has for different reasons. So people have babies, right, and take time off to welcome their children.

People take time off for family-related items. I know I’m taking care of my grandfather, who’s at end of life. And so I’m taking chunks of weeks at a time to go do that. People have been in car accidents, had other accidents, and have needed to take upwards of six to eight weeks off.

But what we don’t hear when people are involved in those sorts of– those drivers of need for time off, we don’t hear people talk about, this is unfair to the other learners. How is this going to impact the other learners? This is really a disability-centric concern. And so it’s really interesting to me that that doesn’t come up as much with other people.

For psychological disabilities, still on the learner with a disability, what’s really important to know is that 40% of medical trainees at any given time are depressed, right? They would qualify for a psychological disability. They would qualify for accommodations.

That’s 40% in medicine. It’s even higher in nursing. And we know of the people who are having these symptoms that a good 25% of them do not disclose.

So the reality of the situation when we’re thinking about people with psychological disabilities is that– and this is shown in my research and others, is that the people who are actually asking for accommodations and enacting some sort of safety net for themselves or the ability to be as productive as possible, those are the people that I don’t worry about. It’s everyone else that winds up having to take an emergency leave of absence or having some sort of psychiatric situation on the wards. But we don’t see that with individuals that are registered.

In fact, we’re doing a longitudinal study looking at the risk of suicide in trainees and whether or not they engaged in disability services. And 98% of those that completed a suicide did not ask for help. They did not engage disability services to ask for accommodations.

So I really don’t worry about this particular group. They go on to match. They perform well. They, in general, don’t have a lot of issues.

Discomfort of coworkers came up. I was kind of surprised about that. And while we see mistreatment by coworkers of disabled physicians– and we see this in race, in LGBTQ and other populations– I wonder how we handle discomfort or microaggressions due to race or sexual identity or religion, for that matter, or gender harassment. And I think as a profession, as kind of the health professions writ large, we need to do a better job addressing these microaggressions and mistreatments that are caused because of people’s identity.

This isn’t just a disability issue. In fact, I would say everything needs to be reviewed through an antioppressive lens, right? We’re oppressing various groups of individuals at rates that are alarming. And we need to look at these things together and bring all of these efforts together.

And I think it’s important to remember that all health professions are competency based. All professionals, whether they’re disabled or not disabled, need to meet the competencies of the program. And so all concerns about safety, all concerns about graduating competent practitioners, yes, those are things that we work on as well. They absolutely have to meet the competencies, no waivers included. But that is very possible.

And I think the reason I wanted you to have front of mind Dr. Crume and Dr. Arnold was because I think many people, if presented with these two applicants, would have layered on lots and lots of presumptions about inability or cost or what would be the concern of the other learners. And I would caution that thinking in anyone because not that long ago, we were doing that with race. Not that long ago at all, we were doing that with gender identity and sexual orientation.

We have done a lot of damage in health professions education. And I think we really need to be thoughtful about how we look at all of the various and beautiful diversity that is coming into the health professions and not treat any one individual or any one class of individuals as someone who is a potential threat because that’s really, at the end of the day, what it comes down to. It may be something you don’t know. And, therefore, it threatens you in some way, shape, or form. And that, by the way, is the basis for discrimination. So we really have to be careful about that.

Someone brought up the experience for the disabled learner. And I really appreciated that. I’m just going to switch back over to the slides. I really appreciated that because that showed me that somebody was really thinking, gosh, if we’re thinking all of this, what’s happening on the learner end?

And I can tell you what’s happening on the learner end is you have people not disclosing because they’re afraid. You have people managing things at alarming rates that have become kind of a part-time job and not telling you what their needs are. And that is not what you want.

All of this, all of what we’re talking about today, all of the assumptions that we’ve discussed have a name. And so we’re going to name it because I think it’s appropriate to do so. And it’s called ableism. And it’s just another form of discrimination or social prejudice against people with disabilities.

And it’s based on the belief that we hold very tight that typical abilities or super abilities are superior to others. You see this in our superhero mindset that we have for all health professions. You see the nurse in the cape, the doctor in the cape, the OT in the cape. The idea that you have to be superhuman to be a physician is harming not only people with disabilities, but it’s harming people without disabilities as well. People are literally killing themselves to live up to that stereotype.

At its heart, really, ableism is rooted in the assumption that people with disabilities require fixing and that if you can’t fix them, that they’re not worthy of being part of this group or part of this profession. Ableism is not that different, really, from racism and sexism. In fact, if I were to take– this is a totally different training, but if you look at the tenets of ableism and the tenets of racism, they’re essentially the same thing, right? You’re judging someone because of something that presents on their body.

Ableism classifies an entire group of people as less than. And it includes lots of harmful stereotypes or misconceptions or generalizations. And I think that’s what you, if you think about it, that’s what a lot of the discussion was today, right? I did hear several people say, gosh, I don’t know, and so I’m just guessing. But it’s that guessing that leads to decisions that is most harmful.

So thinking about this, reframing it through ableism and, let me say really quickly, I’m ablest. And I say that. I giggle a little because it’s an uncomfortable thing to say out loud, right? I live, breathe. I can’t tell you the extent– we can’t go on a vacation without my entire family at this point pointing out the inaccessible spaces on a vacation. We can’t shut our brains off.

This is part of my life. It’s part of my family’s life. It is what I live for, is to change the landscape in health professions education and change the thinking. And yet I’m ableist.

I’m lucky that I have several people around me that get to help me understand. And I spend a lot of time in reflection about my belief system. Other people help me reflect through their observations of what I might say or do. And I’m somebody who thinks about this 24/7. So I even dream about it, to be honest.

So if I’m ablest, the reality is that everyone on this call is ablest. I would argue even Dr. Arnold would say she’s ablest and Dr. Crume. There’s a lot of ableism that goes between different categories of disability towards other categories of disability. And a lot of it is grounded in a lack of education or a lack of experience with people with disabilities in your programs.

So, thinking about it through this lens, I’m wondering, what portions of your barriers are grounded in an ableist belief system? So when you think back– and I’m just going to ask you to reflect on this in the interest of time. I want you to think back to one thing, just one thing that you put forward as a potential barrier. And I want you to think, gosh, did ableism inform that barrier?

And I’ll give you just the example that I used before, the idea that can we– do we have the supports necessary to support this person? That is 100,000% driven by ableism because you are making assumptions about a person’s needs without interacting with them. That’s why the law requires an interactive process, which we’ll talk about a little bit later.

But you saw for Dr. Arnold, what did Dr. Arnold need? A $10 step stool from Walmart, literally. Jen and I were laughing about this. I can’t tell you the number of schools that will call me and say, we have a little person. We don’t know what to do. How are they going to reach the patient to examine them?

And, first of all, your table should be accessible. And that means that they would go up and down to the height needed for anyone, right? But a step stool. It’s as simple as that. That was what she needed.

And yet I promise you the conversations behind the scenes– maybe not at Hopkins. They seem to really get it. But the conversations behind the scenes we’re probably a lot of people having conversations about, I don’t know that we can support someone like this. I don’t know that we’ll be able to afford their needs. So lots of things to think about.

So what are the actual barriers that we find in our data? Well, one is lack of program access. And this really ties into what Dr. Crume was saying, that having the barriers to getting an accommodation– and program access is defined as accommodation or not needing accommodation because something is accessible.

But being able to articulate, identify, understand all of your needs is a pretty hefty lift for someone who hasn’t been in your environment or perhaps hasn’t been part of your profession before. So the lack of someone that specialized to assist them, like Lori was talking about, can be very, very difficult and place a lot of burdens on learners. Thank goodness we have a lot of systems in place to support them now. But lack of program access– and so this could be lack of accommodation. It could be lack of accommodation in admissions, lots of USMLE Step Exam issues, not having accommodations on the Step Exam.

It’s also poor infrastructure or policy. So what do we know about infrastructure and policy? Well, the good news is infrastructure and policy, these are all created by people, right? And, unfortunately, people are bringing their ablest belief systems to the creation of this policy and procedure. But because people develop it, people can also rip it down and rewrite it, recreate it.

We know that lack of infrastructure and lack of quality improvement on this topic is an issue. Nondisclosure, conflicts of interest in the system, failure to properly evaluate learners that are having difficulty for disability, and fitness-for-duty processes that traumatize individuals that are coming back off of a leave. All of this, every single one of these research articles is grounded and driven by an ablest belief system.

Culture and climate– these are known barriers to people with disabilities. So it could be cultural barriers to disclosure, the well-intentioned mentor saying don’t disclose your disability. You will be put in a system and people will never look at you the same.

And, honestly, after some of your talks and coming in and out– and I think you can reflect on this– that there were so many questions, right? There was so much concern that was happening as a result of this pseudo disclosure of disability that you might understand why someone wouldn’t want to disclose across or within your programs.

Burnout, the learning environment being a really harsh learning environment, full of microaggressions and bias, lack of a sense of belonging– for people with disabilities, there’s often the yes and other. So yes, we’ll take you into our program, yet you have to go through all these other systems. And we treat you completely differently. So they don’t feel like they are part of the community.

And then mistreatment, and mistreatment, the mistreatment levels were startling. For those of you that are interested, it was in Health Affairs, but it was like 13 to 30 times more likely to experience mistreatment than other physicians. And physicians are already at baseline pretty horribly mistreated. And this was by peers and patients. We expect this from patients, not from peers.

As an aside, I’ve never heard of a patient not wanting a disabled provider to give them care. In fact, if you listen to our podcast, we have lots of providers on there from multiple specialties. Many of them say or report that the individuals feel a sense of comfort immediately and trust immediately, knowing that their provider has gone through something, that their provider has been a patient as well, that there’s this sense of you know what I’m going through, and, therefore, you will care for me in a much more constructive and thoughtful manner. But all of these things are informed by ableism.

If you want to hear some of the stories of individuals with disabilities, many of the quotes from our work with the AAMC are included in this report. And you can hear in their own words. Today is a very quick overview of the findings.

So very specifically, burdensome processes, making people jump through multiple hoops just to ask for an accommodation, which, as we’ve established, is already hard to do. Technical standards or central functions that really, in practice, do not work, that are something like must be able to hear a heartbeat. You actually don’t have to be able to hear a heartbeat– and I’m happy to argue this with anybody that’s on that wants to argue it further– to be able to make an evaluation. There are actual visual outputs that are a better indicator of the functioning of the heart. And, if you have concerns, you’re actually going to refer your patient to a specialist.

Threats of professionalism citations for disclosing disability, failure to connect disability to mental health supports, so if you have a mental health support system in your program, making sure that those individuals understand that people can also get accommodations to go and meet with their counselors. Defaulting to a leave of absence for anyone that presents with a psychological disability, which is essentially what happens in health professions. And it’s unfortunate because many people can stay engaged in the work and just get an accommodation to meet with a counselor or have a temporary in-patient adjustment of meds or something like that.

Fitness-for-duty evaluations that are extraordinarily harmful and not trauma informed, uninformed DRPs– this is the disability resource professional. As Lori was saying, you don’t have this at the employment level. This is something that not only the AAMC, but the AMA put out a report in 2021 that said every GME program and every UME program needs an informed system of determining accommodations. And that begins with an informed disability resource professional.

Poor messaging or lack of messaging at all about disability inclusion, lack of transparency about your process– I can tell you that I actually, within the greater partner system, every system is very different. And I have had multiple trainees reach out to me to say, there’s no guidance whatsoever to tell me how to request that accommodation.

Uninformed decision making– this is what happens when someone’s meeting with a trainee and doesn’t understand what accommodations are possible and so, therefore, says we don’t know or no, that’s not possible. Or for many of you, you may have the opinion that clinical accommodations don’t occur in your program because it’s a patient safety concern. That’s kind of the one-liner. But the reality is that in any one of your programs, I can show you multiple instances of clinical accommodations. And the law would require you to engage in an interactive process to determine whether or not something is reasonable.

Structures of disclosure that have conflict of interest. So if you have to disclose to your boss or your supervisor, that’s a huge disincentive for somebody with a learning disability or with any disability. And lack of accommodations on high-stakes exams, all grounded in ableism.

Bias, stigma, shame, and bullying– I can’t tell you the stories I’ve heard about bullying from peers, which is heartbreaking to me. Misinformation that gets exchanged colleague to colleague– so if your program is toxic, people will talk about the program kind of in this underground network and say, oh, don’t disclose a disability because you will be chastised. And, therefore, they’re not getting access to the accommodations they need. It may impair their ability to perform in the program. But I can tell you with certainty that it’s going to cause some psychological distress. And there are going to be trust issues.

A clinicalized culture, where we clinicalize everything– someone who’s been a wheelchair user since birth knows how to navigate an environment. In fact, I would argue they probably know how to navigate an environment better than us. They’re probably more nimble in their ability to switch gears and literally and physically to think about how to access things differently.

Negative peer attitudes, restricted views of disability– again, what can you do if you’re a wheelchair user? Or what can you do if you’re deaf or hard of hearing? Honestly, anything.

I have wheelchair users– again, one hand, easily can name five surgeons that are wheelchair users. One was the head of neurosurgery at the University of Michigan. One is a plastic surgeon. One is a general surgeon, one is a pediatric surgeon, and one is a trauma surgeon. All of them are wheelchair users.

So that is not what you would imagine. If I said, gosh, I want you to imagine a learner or a trainee that’s a wheelchair user and what specialty they’re going to go into, I bet no one would say surgery. So that just gives you a little bit of a sense of why do we think this way? Well, because we are taught about disability from a young age. And we’re taught what to think.

We’re taught to feel sorry for people. We’re taught to be helpful to people. We’re taught that they are less than. This the whole premise of ableism. And program access is a huge barrier and, of course, again, all grounded in ableist beliefs.

So I’m choosing to share two things for your program since there are so many programs represented here today. And, by the way, OTs are my favorite people in the world because those are the people that figure out how to keep people employed and engaged in work. And they are my favorite people to bounce ideas off of for accommodations.

Many times they are the most open to disability. And I hope that that’s the case here. But the interactive process is, by far, the largest thing that will trip you up. You have to engage in an interactive process to determine whether an element of the program is essential, whether an accommodation is reasonable. You must offer and deliberate about appropriate reasonable alternatives if you decide something isn’t reasonable. And this must include relevant faculty.

And if you don’t do this and you receive a complaint– today I’m only covering OCR complaints. But I promise you, I’m really good at just bouncing off all of the litigation that’s actually made it to court and to the appellate court as well. There are too many of these cases. And what’s really unfortunate, just to situate– I always like to situate this in the bigger picture– while I’m going to share a few OCR cases as of late, the reality is that even the ability to file a complaint with OCR or the ability to file for private litigation is a privilege, that most of the complainants are white, most of the complainants are upper middle class, most of the complainants have resources.

This is a privileged system we have in the US. And so, unfortunately, the people who are multiply, multiply, multiply marginalized and at most risk don’t have the resources or the time to actually file complaints. So we need to do better. We can’t be driven by litigation or complaint from the Office of Civil Rights. We need to be driven by an internal justice frame that equity is important, equity is important for all people, and that we have to create safe environments where we can have discussions because I promise you, once discussions actually happen in safe and trusting environments, solutions are found 99% of the time.

But my soapbox, back to the complaints– here’s two schools of nursing in the last few years that didn’t follow the process and instead said, you know what? This is a fundamental alteration, which is what we hear a lot in nursing. Sorry, nursing people. But we do have kind of a theme or a thread, if you will, in nursing of the nursing program saying, look, they’re coming from the framework of a bedside nurse who has to be able to do everything, including lift an entire building by themselves– and that’s a joke, obviously.

And the reality is that that may be true. And it may line up with your standards. And your standards may not be discriminatory. And there’s lots and lots of things that we need to tether to to make those decisions.

But when you don’t engage in the interactive process, it doesn’t matter what you decided. The courts will not side with you. You have to go through this process, even if what’s referred to is on its face. So that’s any reasonable person in any room, any sample of people would say, that’s not– that’s not a reasonable request.

Even if that’s the case, even if it meets that standard, if you didn’t go through an interactive informed process, you will not get whatever it is you’re seeking, whether that’s summary judgment or a failure of OCR to pick up the complaint. That won’t happen. You have to go through this process.

OK, so the other one is failure to accommodate. And this is failure to enact or provide reasonable accommodations. And these complaints often include retaliation. So you fail to provide a reasonable accommodation. And then the retaliation is oftentimes the dismissal of the student or refusal to let them back into the program, which is the case here with these two cases. And, sorry, nursing, you get hit again.

There are actually eight OCR complaints in Health Sciences in the last three years. And the majority were from nursing programs or medicine programs. So that doesn’t mean the rest of you are off the hook. It just means this is where they’re coming from right now.

And, again, this complaint with the American University of Health Sciences Nursing Program, and then the University of Colorado Anschutz Medical Campus actually has a complaint that’s gone through twice. Their Dean said, I am not doing this. This is not happening. I don’t think it’s reasonable. Therefore, I’m the judge, the jury, and the executioner.

And the Office of Civil Rights said, you know what? Sit down. Hold my beer. No, just kidding.

But they did say, sit down. We are going to oversee all of your decisions now because you clearly are not capable of making that decision. And OCR puts it in much more legalese and in a much more nice way. But yes, it’s essentially sit down.

So what are the facilitators? I’ve told you all the things that provide barriers to health science education. What are the facilitators?

Well, structurally, having an informed DRP, this is the number one thing. Positive messaging, I want all of you– you all have homework. I’m so sorry. I want all of you to go to your websites.

And I want you to, as a potential person with a disability, navigate your website. If you were a person with a disability looking for that resource, whatever that resource is, so as an employee, as a trainee, I want you to navigate that website. And I want you to see what your students experience or what your trainees experience in your program.

What is the messaging? Is it super legalese, kind of grounded? Probably. You don’t have to recite the law for the law to be applicable to your program. You can add nice things in. It doesn’t change the law. So saying that you value diversity and that includes disability is a really great place to start.

Transparency of the process– you must be transparent. People must understand how to get to you. A neutral party to adjudicate the decision, so your boss isn’t the person making the decision.

A timely process– as you know, especially in the training programs, a week can be a month. A month can be a year. We go fast and furious, as we’ve all talked about. And so a timely process is essential. Using functional technical standards that recognize that things like amplified stethoscopes can be used, and if you’re deaf, it doesn’t mean you can’t be a doctor, and culturally, a welcoming culture that understands and expresses the value and ability of people with disabilities.

And then you have a ton of orgs for your schools, for your employment situations. Do you have an ERG, employee resource group– I think that’s what they’re called– or an affiliation group to support people with disabilities? Because finding other people with disabilities, just like finding other people like you and other underrepresented groups can be a lifeline and a support system to feel like you’re not alone and that you belong. It often can also be the catalyst for change.

And develop a robust disability policy, one that encourages disclosure, speaks to privacy of information, identifies that ADA representative, lists the documentation requirements. So there’s nothing worse than going to a meeting to find out you have to make another meeting. Death by meetings is a real thing. Hopefully all of you get that. I don’t have to explain it.

But it really is. Especially for somebody who’s training, who’s doing 12 hours, 18 hours, they don’t have time to do this. Give them up front everything they’re going to need for that meeting. List the steps in the process so that they have an expectation.

We all expectation set with our children, right? I expectation set with my husband all the time. This is what time I’m going to be available today. We need to do that for learners so that they feel a comfort. There’s a comfort in understanding what’s next, right?

List the projected timeline for the accommodation process. And I’m here to tell you, if it’s over two weeks, you’re not in keeping with best practice, according to OCR. So all decisions should be turned around within two weeks and accommodations implemented.

Encourage early disclosure. Why is it important to have early disclosure? Well, once you get into a deficit cycle, you’re in it. Climbing out of it is nearly impossible when you’re also trying to enact accommodations and do everything. The best time to ask for accommodations is before you ever enter the training site, before you ever enter the training program, to have all of that managed.

And tell trainees how to appeal a decision. That’s actually a legal obligation, both under Title I and title II. You have to have a grievance policy. You have to have an appeal policy.

So if you don’t have one, which I promise you, if you’re in medicine at least I can say, my research shows that 40% of you don’t. You have to have one. That’s actually a legal requirement.

And then the steps, the interactive process that I’ve been talking about this whole time. It’s really, really important. It includes not only the designee for the program and the trainee, but it includes people like the program director or the faculty.

And all of the things that have to be brought to the table to understand whether something is reasonable and effective, we created an eight-step process in both our trainings and codified it in the literature. And I’ll send these slides to Lori for anybody that wants them.

So post your policy widely. It’s not enough to create a policy. You have to make sure that people know it, right? You have to disseminate it.

So post to your website a staff handbook. Talk about this during orientation. Talk about it during any invitations to do an interview with your program or any other engagements.

And then ensure that disability is part of your DEI or JEDI affiliation groups and activities. If you leave disability out of diversity, you’re not talking about diversity. As I said, the parallels between racism and homophobia and all of the other isms are deeply, deeply connected. And so if you’re going to talk about diversity and the benefit of diversity, you have to talk about people with disabilities.

Highlight stories of people with disabilities in your program. That’s a great way to encourage other people to disclose, oh, somebody was in the program and they’re talking about it publicly. Publicly? Oh my gosh. This program must be amazing.

Have disabled scholars and providers present grand rounds. I would love to see Jen Arnold talk about her simulation program. I think that would be amazing.

I love simulation. To me it’s a playground. It’s like the adult playground we all go to for health professions. And we try out new things. I would love to see Jen talking about that.

While it’s important to talk about disability, it’s important for disabled scholars to be invited to talk about their area of expertise, right, not just about disability. And then plan for disability programming across DEI efforts. And remember that disability cuts across every other identity.

So we talk about intersectionality. There is a ton of intersectionality happening in this space. You can be a queer, Black, disabled, first-generation scholar. These are all identities that you can hold. And each of them individually is likely to lead to barriers in the system but collectively could be exponentially impactful. And so we need to really be paying attention to this.

What I would say is access is critical. Program access is critical. Our research is finding that– we have another paper coming out in a few weeks. It’s clear, program access is critical to the success of people with disabilities. But new papers coming out six months from now will show you the research we have, the data we have, the belonging and trust in the system is what will get people to the space of asking for accommodations. So while access is critical, you’re not going to get it without belonging and trust.

I have several resources for you to consider today. I’m sorry. Again, I do work in medicine mostly. I am working with the AACN right now on a few projects.

But I have several organizations under our Docs With Disabilities umbrella. And Docs With Disabilities is everybody. One is called Disability in Graduate Medical Education. It’s a community of practice.

And there are some webinar series we just did with the Josiah Macy foundation on barriers and belief systems. These were all focused on medical education. But for the nurses on today’s webinar or training, the Josiah Macy Foundation and I are doing Barriers and Belief Systems– Nurses With Disabilities. That is coming out in June, July, and August. And so that information should start to be advertised fairly soon from Macy.

The AMA did a disability webinar on innovations in medical education regarding disability. And while this was posed for medicine, I would say this particular webinar is really applicable to numerous health professions programs, Similarly, the AAMC and I collaborated on a 10-webinar series about discrete issues in medical education. But also these are widely applicable to health professions.

And then my program is the Docs With Disabilities Initiative. And under the Docs With Disabilities Initiative– you can follow us on Twitter @docswith. And the Docs With Disabilities Podcast is my third child. It’s my labor of love. We share stories of all types of providers with disabilities, what they went through in training, what was good, what was bad, what they advise future providers in the pathway or thinking about entering the pathway, how they advise them.

I will say we have about 50,000 listeners. Our last episode was viewed by over 100,000 people. It has taken off in a way I never would have expected.

The stories are moving. They’re impactful. They’re educational. But, importantly, because there’s a dearth of people with disabilities in health professions education, they are providing a part-time solution to a gap in mentorship that we see and that can really, if you think about all the mentors that helped you get to where you are, lack of mentorship is disastrous for anyone. And so through this podcast, we tried to provide asynchronous mentoring.

And then we’re going to switch over to Poll Everywhere, where you can ask anonymous questions. And Joe is going to run that.

Thank you so much for inviting me. Thank you so much to Dr. Arnold and Dr. Crume for sharing their personal stories, which I think are so essential to understanding and mythbusting about what’s possible. But thank you for coming together for this environment and for being so open in the breakout rooms. That was really great to see that you could really have these conversations.

I’m happy to answer any question that you have. And it’s always my honor to talk about this topic. Thank you, Lori, for inviting me. And thanks to the team for a very well-organized event.

LORI NEWMAN: OK, thank you. And we definitely want to make sure we get to people’s questions. So if you could stop sharing, Lisa. And then Joey is going to put up a Poll Everywhere. So we can all anonymously ask any last remaining questions that we have.

So you need to text medical education to the number 22333. And then you can text your question.

LISA MEEKS: If any of you are interested in the research or the numbers, you can find all of that through my Google Scholar. But we are putting together– we actually are mapping all of the known– all of the known outcomes and all of the research on disability. And we’re going to make that publicly available.

So we’re doing that. We just reached out to all of our international scholars in disability and asking them to contribute to it. So you’d be able to map what’s happening and what we know and what we need to learn.

With ableism in mind, to what extent is disability– I think that might have been defined and maintained– just, oh gosh. I don’t know. Joe, you may have to capture these because if it’s going to run, I won’t be able to– remember, we all process on a spectrum.
JOEY FOURNIER: I can scroll through.

LORI NEWMAN: I think this scrolls up. Yeah.

LISA MEEKS: Oh good. OK. With ableism in mind, to what extent is disability to find and maintained by ableist policy? What qualifies as a disability and what does not well? That’s a great question. I’m going to assume the question– if it’s different please, feel free to– you can always chat me a question as well.

So what qualifies as a disability and what doesn’t? Well, any category of mental or physical impairment, as it’s written under the ADA, would qualify as a disability if there is a functional impairment associated with that setting. So I could be disabled and not disabled in one setting and disabled in another setting, if that makes sense.

So if I’m a wheelchair user– and, by the way, that is– I always want to teach as I go along. That is the correct way to talk about people that are using wheelchairs, not somebody confined to a wheelchair, not somebody in a wheelchair, certainly not somebody stuck in a wheelchair. Just as an aside, the wheelchair gives them the ability to move through their days and accomplish their goals. It becomes part of their bodies. And they don’t feel stuck. They feel a sense of freedom because of what that chair does.

So does it rise to the level of being disabling, which is the functional impairment assessment? So is there something in the environment, in the surroundings, that keep someone from doing their job or navigating throughout their day? So thinking about this in terms of space– we talked about the ED– having access to a computer that is at the level somebody would need if they’re a wheelchair user, if it’s not there, that would be a barrier. That would lead to functional impairment because the person couldn’t do their job, because they couldn’t reach the computer.

Lowering it would be the accommodation. And, therefore, they would have access. That person, though, may not have any issues at home because they may have a completely accessible home.

What advice do you have for academic promotion and advancement? I love this question because our disabled scholars are left behind all the time. In order to be promoted– think about your promotion. I just went through it. So I know. And I’m like, it was so horrible that I just want to get professor over with. And so I’m working really hard to just get it done.
You have to have an international reputation. You have to get invited for talks like this. You have to publish.

If you have a disability and you have to manage your disability– say you have a chronic health issue. I do. I was not disabled when I started this work. And to date, I mostly navigate my life without disability.

But I have a degenerative disease that I will be very disabled at some point in the next 20 years. So I think about– I think about this and going through promotion. If somebody has to take care of their health and they don’t have all the time or if travel– for me, travel is very difficult because it– anyway, it results in a lot of pain at times. So if somebody has to travel to do presentations, they could miss out on those opportunities.

A really good example is for somebody that’s deaf or hard of hearing, going to a conference that’s completely inaccessible without an interpreter– we all know at a conference, going into a talk– say they have an interpreter for the talk. OK, great. You had access to that talk. Where is all the good stuff happening? Is it happening in that talk?

For those of you who are academic scholars, it’s happening in a bar mostly or a restaurant or in the hallway, right, or after the talk. It’s never happening in the talk. All of the opportunities to make friends and make relationships and collaborations– I collaborate with people all over the world.

It didn’t happen in a talk. It happened usually over a drink, usually in the hallway, something like that. If you don’t have an interpreter for those settings, you are left behind. If you are somebody that is low vision and can’t travel without assistance, you are left behind. You don’t go to conferences because the cognitive energy it takes you to navigate a conference is too much, right?

During COVID, a lot of people got an opportunity to do things that they wouldn’t have been able to do otherwise because everything went online. But it still doesn’t help with the meetings that happen in the hall, those exchanges that are needed. You need to collaborate.

So what my group has done is we only work– well, I would say– not only, about 90% of the people we work with are people with disabilities. We are committed to having an investigator and a student, a learner, a trainee with a disability on every project so that they get sponsored and mentored throughout the process, so that they are published.

My students, by the time they graduate from medical school, they have four publications. They have their choice of residency program. They have gone to the AAMC or they’re– I’m taking four students internationally this year to present. They will have CVs that rival their peers.

And them having a disability is valuable. And people with disabilities have a lot to add to this research. But I think my advice is get involved with– get involved with people that are doing the work that will support you in any accommodations that you need.

The other thing that I would say is teamwork. I work in big teams. I don’t work alone. And that has allowed not only me to advance the agenda that we have for disability inclusion, but it’s better informed work. It’s impacted a lot of people. I just think working in big groups has a lot of benefits. Plus, if one team member is down, it doesn’t stop the work from moving forward.

Sorry, that was a long answer. I have a lot of colleagues who are disabled and did not get a lot of opportunities to advance their career. And so it’s a particular area for me.

If supervisors can’t ask clinical info, how do they be– how are they responsible for creating accommodations? You’re just enacting the accommodations. You don’t need to know anything, actually, to do an accommodation.

Let’s say the student has a voice-to-text technology to be able to write their notes. All you have to do is make sure that that’s onboarded. Usually IT will do it. And there’s nothing for you to do.

For ADHD, the accommodations, usually people don’t have accommodations in the clinical setting when they have ADHD. If they do, it’s to wear noise-canceling headphones. And that’s not something– to my knowledge, I see a lot of that happening without accommodation.

But you certainly don’t need to know anything clinical for those invisible-related disabilities. Even the person that had epilepsy, that was actually a learner of mine, a surgeon, which may freak all of you out, an OB/GYN, so subsurgical specialty. And the person was perfectly fine. The epilepsy was well managed, hadn’t had episodes for years.

And it was the sleep deregulation that caused an episode. And that person just, we just rearranged the schedule so that they would be on days fully and that if they had to go to nights fully that they would have a significant amount of time in between to adjust. And that was a resident.

Can we go up? For places without an informed advocate– so just really quickly, this is not an advocate. This is the disability resource professional.
This person straddles access. So they are an agent of the institution and the program. They’re supposed to be informed by the curricula, informed by the essential functions of the program, informed by disability law and clinical accommodations.

And while some of that may be viewed as advocacy, I don’t see this as an advocate role. Advocates have a very different role. This is a person who is making an informed and, by the way, legal consequential decision, right? So this is a really highly educated, highly skilled person in this space.

But is there an external resource we can look into? Yes. So that’s a great question. One of the things that we’re talking about right now is almost like a hotline, if you will, getting funding for a national center for accommodation where people who don’t have that funding to have this person– although all of you, just so you know, have to have someone whose job this is by law.

Now, what happens, depending on the space you’re in, sometimes people get voluntold that this is their job and they have no skills. But it’s like job number six that they have in their repertoire. But we’re talking about getting funding for a national center, where you could call in and get resources and things like that.

If I win the lottery, I’m doing it. So hopefully all of you can send me good juju for the lottery. And then it’ll be done. And then you’ll have free access to really good information.

Do you suggest opening up this– yes, yes, yes, yes. Given the high rate of hidden disabilities and disabilities that are not disclosed, do you suggest opening up this conversation with all learners along the lines of asking at the start of the rotation, how can we make this an optimal learning experience for them? I love that.

Yes, you should do this. And you should be doing it at orientation. They should be getting it in their letter of acceptance or match or employment.

But yes, you should not assume that people don’t have disabilities. 85% of the people who respond to our research are people with disabilities that you would– we call them nonapparent, just because invisible has this weird, like you’re hiding something. And that’s not the intention. But nonapparent disabilities are the majority of disabilities. Yes. And, to be honest, even people without disabilities could have their learning experience optimized with few changes.

Great question. Is there evidence of more medical errors by clinicians who are disabled? Yes. My paper in– I don’t know if it’s JAMA or JAMA Open, one of the two, 2021, so it’s Meeks et al. There’s a but that goes with this.

What we looked at was three groups. So group number one, not disabled. Group number two, disabled and not having program access. So these are the people who were afraid to ask for accommodations. They did not have accommodations. Make sense?

Those people had a higher rate of medical errors than disabled individuals that had accommodations. So disabled individuals that had accommodations and nondisabled individuals had the same number of medical errors, almost exactly the same number of medical errors reported. People that were disabled and did not have program access not only had a higher number of medical errors, but they also had an increase in depressive symptoms.

And this was a study specific to intern physicians. So for those of you not in medicine, that’s the first 12 years of training, so the first year after medical school. And so it’s a very specific group.

But the findings were startling. And that is one of the reasons– one of a number of studies that we’ve done where we have concluded that program access is just essential. And how do you get program access? Well, you can’t have it if people don’t disclose.

How do you get people to disclose? It’s kind of like who’s on first, right? How do you get people to disclose? Well, you have to create a welcoming, supportive, safe environment for people to disclose because if they don’t, there are potential consequences.

OK, a faculty or an employee becomes disabled. What’s the institution’s obligation to accommodate them? Well, that’s a red herring question because a faculty or an employee becomes disabled, the institution’s obligation is to engage them in the interactive process.

That’s the obligation. There’s no obligation to accommodate that’s kind of this direct, I’m disabled, you must accommodate me. It’s to go through that process.

Now, the EEOC will say you have an obligation to provide reasonable accommodations in a workplace setting that do not challenge the essential functions of the job. So an example, if you have a security guard and their job is all day every day to evaluate people coming in and have them go through the scanner, right, and they lose their vision and they lose their hearing, are you obligated to accommodate them with another security guard who can do the job for them because they are now disabled? And the answer is no, right? So the person still has to be able to do the essential functions of their job. Or, in many cases, we see a slight modification to the essential functions, like job sharing.

Or I have a friend who became disabled who’s now a radiologist. He doesn’t do any interventional work because he doesn’t have enough of the– or he doesn’t do any of the dyes. He doesn’t inject people with stuff. Somebody’s always on call to be able to do the injections. And he reads the radiograph because he doesn’t have the dexterity to do that.

So the obligation is not to accommodate directly. The obligation is to engage in the process. I hope that makes sense. If it is a reasonable accommodation, though, then yes, the institution would be in trouble.

I will say for trainees, the legal space is very awkward. And sometimes their contracts make it really difficult for them to sue if they’re nonaccommodated. And understand, too, for those of you who work with trainees across any group, a trainee– actually, if the institution won’t accommodate and the options are to sue or file a complaint with the EEOC or do nothing, most of them will choose to do nothing because the act of doing something is risking their career.

And so it’s really unfortunate because most institutions have people with disabilities in this box, right? And if they do anything, then in order to, especially to sue, you have to– all of your information is public. I can go to any lawsuit and read all of the details of someone’s disability. So it’s very difficult on a person to enact that system.

LORI NEWMAN: With that, I also want to just comment about this question about a faculty or employee becomes disabled. One bright note is that I spoke to the head of social work. There is a committee at Boston Children’s Hospital that looks at accessibility for patients who are coming to the hospital to receive care or if there’s any complaint regarding mistreatment because of their disability. So there is a committee that is formed for patients.

And I was also informed that HR is considering hiring a social worker, who I assume has the professional expertise to help with implementation of accommodations for those employees who are injured on the job. So there is movement forward, at least in that way.

OK, I wonder– it’s almost 3:15. Lisa, I think, probably needs a glass of water. So, Joey, I think we should take this down. If we didn’t answer your question, please email the BCH Academy. And we will be sure to reach out to Lisa or to our other resources and make sure we do get a response for you.

But I want to, again, thank Lisa, Jennifer Arnold, Bonnie Crume, our facilitators for helping to lead today’s session. I have one last ask for you. I know it’s been three hours.

But what I think would be really great as a teacher– and Lisa is, obviously, a masterful teacher– is to hear what change you are going to make because of this afternoon. And the ripple effect is probably the greatest gift you can give to a teacher. So in the chat, if you could please just type in what change you plan to make as a result of attending today’s retreat, I think that would be, again, a really wonderful thank you and parting gift to Lisa and all of our facilitators.

LISA MEEKS: And I will just say, my goal is always, you can’t possibly know everything. I don’t know everything. There’s so much. There’s just so much out there on disability, especially research and telling the wider story.

However, if all today accomplishes is to get you to stop when you have these automatic thoughts, first of all, to understand that we all do, to when you have these automatic thoughts, stop and say, am I having an automatic thought that’s not informed by facts, and which we should do with everything, right, and to disrupt that by– just you stopping and reflecting on that disrupts the process of ableism. And reaching out and just really thinking about things logically and making sure that decisions are fact based, I think that’s really, really important.