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Disability as Diversity: A Case Studies Companion Guide [1st ed.]
 9783030558857, 9783030558864

Table of contents :
Front Matter ....Pages i-xiv
Front Matter ....Pages 1-1
The Student with a Learning Disability: Clarissa Connors, a Medical Student with Undiagnosed ADHD and a Learning Disability (Kristina H. Petersen, Stacy C. Jones, Lisa M. Meeks)....Pages 3-15
The Student with a Physical Disability: Tammy Thomas, a Clinical Year Medical Student with Quadriplegia (Christopher D. Connolly, Maya M. Hammoud, Charlotte H. O’Connor)....Pages 17-23
The Student with a Sensory Disability: Conrad Barker, a Rising Third-Year Medical Student with Hearing Loss (Michael S. Argenyi, Alicia Booth, Christine Low)....Pages 25-36
The Student with a Psychological Disability: Rhonda Rapp, a Fourth-Year Medical Student with Depression and PTSD (Lisa M. Meeks, Hilit F. Mechaber, Samantha Schroth, Rahael Gupta, Joseph F. Murray)....Pages 37-45
The Student with a Chronic Health Condition: Hillary Hampton, a Second-Year Medical Student with Crohn’s Disease (Nichole L. Taylor, Charlotte H. O’Connor)....Pages 47-54
The Student with Cancer: Marc Fernandez, a Fourth-Year Medical Student with Cancer (Nichole L. Taylor, Catherine Moore, Suzanne Hawks)....Pages 55-65
Front Matter ....Pages 67-67
The Student with a Learning Disability: Mee Sook Smith, a Nursing Student with a Learning Disability in an Associate Degree Program (Leslie Neal-Boylan, Patricia Lussier-Duynstee, Christine Low)....Pages 69-75
The Student with a Learning Disability: Maxwell Mason, a Nursing Student with a Learning Disability in a Baccalaureate Degree Program (Patricia Lussier-Duynstee, Charlotte H. O’Connor, Leslie Neal-Boylan)....Pages 77-83
The Student with a Physical Disability: Sam Stone, a Nursing Student with a Missing Limb (Leslie Neal-Boylan, Patricia Lussier-Duynstee, Jan Serrantino-Cox)....Pages 85-93
The Student with a Sensory Disability: Anna Howard, a Deaf Nursing Student (Stacey M. Carroll, Carrie Morgan Eaton, Marie Lusk)....Pages 95-107
The Student with a Psychological Disability: Melanie Mathews, a Nursing Student with Suicidal Ideation (Leslie Neal-Boylan, Michelle D. Miller, Jan Serrantino-Cox)....Pages 109-116
The Student with a Chronic Health Condition: Susan Nacht, a Nursing Student with Narcolepsy (Sharron E. Guillett, Elizabeth Kane)....Pages 117-124
Front Matter ....Pages 125-125
The Student Using Medical Marijuana (Leslie Neal-Boylan, Charlotte H. O’Connor)....Pages 127-132
The Student Who Brings an Animal to Class (Patricia Lussier-Duynstee, Christine Low, Elisa P. Laird, Leslie Neal-Boylan)....Pages 133-139
The Student Who Fails the Medical Board Exam (Kristina H. Petersen, Lisa M. Meeks)....Pages 141-151
Back Matter ....Pages 153-158

Citation preview

Disability as Diversity A Case Studies Companion Guide Leslie Neal-Boylan Lisa M. Meeks Editors

123

Disability as Diversity

Leslie Neal-Boylan  •  Lisa M. Meeks Editors

Disability as Diversity A Case Studies Companion Guide

Editors Leslie Neal-Boylan Mansfield Kaseman Health Clinic Chevy Chase Rockville, MD USA

Lisa M. Meeks Department of Family Medicine University of Michigan Medical School Ann Arbor, MI USA

ISBN 978-3-030-55885-7    ISBN 978-3-030-55886-4 (eBook) https://doi.org/10.1007/978-3-030-55886-4 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to disability resource and student affairs professionals, faculty, deans, and champions for diversity, equity, and inclusion who work together to ensure access in health science programs across the country.

How to Use This Book

This casebook is designed to be a companion resource for the book Disability Inclusion: Disability as Diversity. We recommend reading that book first or in conjunction with the casebook. The casebook includes cases informed by disability professionals, faculty, and administrators in nursing and medicine, but is applicable to a number of health science programs. Each case includes a history introducing the student and the scenario, followed by perspectives on challenges and concerns from the point of view of the student, the program, and the disability resource professional. These perspectives assist the reader with understanding the various points of view, giving them a full 360-degree view of how each party perceives a disability-related barrier. This perspective taking aids the reader in understanding the punctum caecum of each stakeholder. The perspective part is followed by a deconstruction of the disability-related barriers by asking the reader three critical questions needed to move through the case: What do we know? What do we need to know? How and where we can access the information? In this part, we critically analyze the case and identify the information and resources needed to develop a solution. Following this deconstruction, the authors present several questions for discussion. These are intended as prompts to stimulate a larger conversation about accessibility. Finally, each case concludes with a description of the accommodations that reduce barriers and provide equal access for the student, with specific reference to guidance from the book Disability Inclusion: Disability as Diversity. Our sincere thanks to disability resource and student affairs professionals who work to ensure access in programs across the nation. – Leslie and Lisa

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Introduction

This casebook is intended as a companion to the book Disability Inclusion: Disability as Diversity, which offers a practical guide to eliminating barriers to student success and fostering a culture of true inclusion for people with disabilities in academic settings. It addresses the most salient questions facing faculty, staff, and disability resource professionals (DRP). This casebook serves as a partner to the original text, providing thoughtful review of scenarios, informed by a compilation of real-life experiences. While this casebook is useful as a companion, it also benefits the reader as a stand-alone tool for workshopping potential scenarios among disability staff and as a tool for faculty training. It can also be used to increase awareness among medical, nursing, and health sciences students in classes that discuss disability, improving the climate for disabled individuals in education and employment. As with the original book, this casebook companion is not intended to give legal advice or substitute for sound and frequent dialogue among faculty, administrators, DRPs, and students with disabilities. Legal representatives to schools and universities should be consulted, as needed, to verify how the law is interpreted within the scope of their program and, if applicable, their state. As with the book Disability Inclusion: Disability as Diversity, we recognize that it is helpful to discuss medical and nursing students separately given the differences in curricula and accreditation requirements. Yet the authors have worked to ensure that the scenarios in this casebook are broad enough to apply to other health sciences students. We encourage faculty and disability staff to utilize this book as a bridge to understanding the perspectives and challenges inherent in each role and to work collectively towards greater access, understanding, and appreciation of the multiple stakeholders that guide students in their paths to become healthcare professionals. Rockville, MD, USA Ann Arbor, MI, USA

Leslie Neal-Boylan Lisa M. Meeks

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Contents

Part I Medical Student Cases 1 The Student with a Learning Disability: Clarissa Connors, a Medical Student with Undiagnosed ADHD and a Learning Disability��������������������������������������������������������������������������   3 Kristina H. Petersen, Stacy C. Jones, and Lisa M. Meeks 2 The Student with a Physical Disability: Tammy Thomas, a Clinical Year Medical Student with Quadriplegia ������������������������������  17 Christopher D. Connolly, Maya M. Hammoud, and Charlotte H. O’Connor 3 The Student with a Sensory Disability: Conrad Barker, a Rising Third-­Year Medical Student with Hearing Loss����������������������  25 Michael S. Argenyi, Alicia Booth, and Christine Low 4 The Student with a Psychological Disability: Rhonda Rapp, a Fourth-­Year Medical Student with Depression and PTSD ����������������  37 Lisa M. Meeks, Hilit F. Mechaber, Samantha Schroth, Rahael Gupta, and Joseph F. Murray 5 The Student with a Chronic Health Condition: Hillary Hampton, a Second-­Year Medical Student with Crohn’s Disease��������������������������  47 Nichole L. Taylor and Charlotte H. O’Connor 6 The Student with Cancer: Marc Fernandez, a Fourth-Year Medical Student with Cancer ������������������������������������������������������������������  55 Nichole L. Taylor, Catherine Moore, and Suzanne Hawks Part II Nursing Student Cases 7 The Student with a Learning Disability: Mee Sook Smith, a Nursing Student with a Learning Disability in an Associate Degree Program ����������������������������������������������������������������������������������������  69 Leslie Neal-Boylan, Patricia Lussier-Duynstee, and Christine Low

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Contents

8 The Student with a Learning Disability: Maxwell Mason, a Nursing Student with a Learning Disability in a Baccalaureate Degree Program��������������������������������������������������������  77 Patricia Lussier-Duynstee, Charlotte H. O’Connor, and Leslie Neal-Boylan 9 The Student with a Physical Disability: Sam Stone, a Nursing Student with a Missing Limb��������������������������������������������������  85 Leslie Neal-Boylan, Patricia Lussier-Duynstee, and Jan Serrantino-Cox 10 The Student with a Sensory Disability: Anna Howard, a Deaf Nursing Student ����������������������������������������������������������������������������  95 Stacey M. Carroll, Carrie Morgan Eaton, and Marie Lusk 11 The Student with a Psychological Disability: Melanie Mathews, a Nursing Student with Suicidal Ideation������������������������������������������������ 109 Leslie Neal-Boylan, Michelle D. Miller, and Jan Serrantino-Cox 12 The Student with a Chronic Health Condition: Susan Nacht, a Nursing Student with Narcolepsy���������������������������������������������������������� 117 Sharron E. Guillett and Elizabeth Kane Part III Focused Topic Cases 13 The Student Using Medical Marijuana��������������������������������������������������� 127 Leslie Neal-Boylan and Charlotte H. O’Connor 14 The Student Who Brings an Animal to Class������������������������������������������ 133 Patricia Lussier-Duynstee, Christine Low, Elisa P. Laird, and Leslie Neal-Boylan 15 The Student Who Fails the Medical Board Exam���������������������������������� 141 Kristina H. Petersen and Lisa M. Meeks Conclusion���������������������������������������������������������������������������������������������������������� 153 Index�������������������������������������������������������������������������������������������������������������������� 155

Contributors

Michael  S.  Argenyi, MD, MPH, MSW  Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA Alicia Booth, BS, BA, NIC  Designated Interpreters LLC, New York, NY, USA Stacey M. Carroll, PhD, APRN, ANP-BC  Rush University College of Nursing, Chicago, IL, USA Christopher  D.  Connolly  University of Michigan Medical School, Ann Arbor, MI, USA Carrie  Morgan  Eaton,  Ph.D., MSN, RNC-OB, C-EFM, CHSE  University of Connecticut, Storrs, CT, USA Marie Lusk, M.B.A., M.S.W., L.S.W.  Rush University, Chicago, IL, USA Sharron  E.  Guillett,  PhD, RN  Elizabeth Wade Custer School of Nursing, Shenandoah University, Winchester, VA, USA Rahael  Gupta,  MD  UCLA Angeles, CA, USA

Resnick

Neuropsychiatric

Institute,

Los

Maya M. Hammoud, MD, MBA  University of Michigan Medical School, Ann Arbor, MI, USA Suzanne Hawks, BS  Wake Forest University, Winston-Salem, NC, USA Stacy  C.  Jones,  MD, EdM  Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA Elizabeth  Kane,  MA  Academic Enrichment Center, Shenandoah University, Winchester, VA, USA Elisa  P.  Laird,  JD  Disability Resource Center, Samuel Merritt University, Oakland, CA, USA Christine  Low,  LCSW-R.  Icahn School of Medicine at Mount Sinai, New York, NY, USA

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Contributors

Patricia Lussier-Duynstee, PhD RN  Assistant Professor Emerita (Retired), MGH Institute of Health Professions, Boston, MA, USA Hilit  F.  Mechaber,  MD  University of Miami Miller School of Medicine, Miami, FL, USA Lisa  M.  Meeks,  PhD, MA  Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA Michelle D. Miller, JD, MPH  Quinnipiac University, Hamden, CT, USA Catherine  Moore,  MD  Department of Obstetrics and Gynecology, George Washington University, Washington, DC, USA Joseph F. Murray, MD  Weil Cornell Medical College, New York, NY, USA Leslie  Neal-Boylan,  PhD, APRN, CRRN, FAAN  Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA Charlotte H. O’Connor, MEd  Office of Medical Student Education, University of Michigan Medical School, Ann Arbor, MI, USA Kristina H. Petersen, PhD  New York Medical College, Valhalla, NY, USA Samantha  Schroth  Northwestern University Feinberg School of Medicine, Chicago, IL, USA Jan  Serrantino-Cox,  EdD  Coalition for Disability Access in Health Science Education, Rancho Santa Margarita, CA, USA Nichole L. Taylor, DO  Wake Forest School of Medicine, Winston-Salem, NC, USA

Part I Medical Student Cases

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The Student with a Learning Disability: Clarissa Connors, a Medical Student with Undiagnosed ADHD and a Learning Disability Kristina H. Petersen, Stacy C. Jones, and Lisa M. Meeks

Case History From the first day of medical school orientation, Clarissa felt out of place. While most of her medical student peers were from affluent backgrounds, Clarissa came from a low-income family and was still struggling financially. She majored in Spanish and American Sign Language, while most of her peers were science majors, and some had graduate degrees. Clarissa’s sense of “otherness1” intensified on the first day of classes, when she found herself unable to keep up with and comprehend lecture content. She left after the first four hours of class, opting instead to study on her own and watch lecture recordings at her own pace. Clarissa quickly became frustrated at her inability to finish the daily readings for each course. She could only get through a few pages and retained very little. Clarissa encountered further barriers in small group sessions, in part because she had not completed the assigned readings. She also had difficulty following the group’s conversations and often felt lost. Feeling ashamed and frustrated, she participated even less, was often close to tears, and avoided professors, small group leaders, and advisors for fear they would think she was lazy.  “Otherness” is defined as the feeling of not fitting in.

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K. H. Petersen (*) New York Medical College, Valhalla, NY, USA e-mail: [email protected] S. C. Jones Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA e-mail: [email protected] L. M. Meeks Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_1

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Despite these struggles, when items were assigned the night before, Clarissa often felt able to prepare and thus participate. When this occurred, small group leaders noted that Clarissa seemed to have a decent grasp of knowledge and was good at seeing the “big picture.” In fact, Clarissa was often able to identify gaps in colleagues’ reasoning. Despite Clarissa’s struggles, family history of learning disabilities, and ADHD, Clarissa failed to recognize herself as a person with a “disability.” She was not even aware of the option to apply for accommodations. For many years, Clarissa had developed approaches to her academics that allowed her to naturally compensate for her undiagnosed disabilities. For example, during high school and college, she’d been academically successful and kept up with her peers by taking summer courses to ease her course load and worked directly with instructors to modify assignments as needed. When she began to struggle in medical school, her academic advisor suggested the barriers she was encountering  were consistent with individuals who had learning disabilities, and recommended she consider being evaluated. Although the advisor mentioned she may be able to get accommodations like extra time on exams, Clarissa was very hesitant. In addition to the fear of being stigmatized, she did not feel that applying for accommodations was an option because she had never been diagnosed with a disability. She also knew that she would not be able to afford the neuropsychological evaluation, a $5000 expense not covered by her insurance. Clarissa experienced considerable anxiety over her struggle to “keep up” with coursework, her inability to request accommodations in the absence of documentation, and the financial burden she would face if she got formally evaluated. She felt increasingly isolated from her classmates. Clarissa had been meeting with her school’s learning specialist to improve her study strategies. Their plan included reading aloud, drawing pathways, organizing notes in space and by color, utilizing review books, completing practice questions, and handwriting a brief log of each small group session. Although implementing these techniques proved helpful, Clarissa still struggled to keep up with coursework and performed poorly on exams. Concerned she may be at risk for dismissal from medical school, she increased her financial aid loan to move forward with the neuropsychological evaluation. The report revealed multiple deficits in written and verbal language processing and evidence of ADHD.  The neuropsychologist recommended several accommodations, including extended time on exams in a reduced distraction environment and the use of text-to-speech technology. Clarissa met with the official who approved accommodations at her institution. Unfortunately, this person was not specialized and had no expertise beyond approving the accommodations suggested by the student’s evaluator. Thankfully, the accommodations recommended by the neuropsychologist were approved for the didactic setting, and once implemented, Clarissa’s examination scores improved drastically. As her grades increased, her feelings of isolation and anxiety lessened. Clarissa successfully passed her first- and second-year courses allowing her to stay on track with her graduating class.

1  The Student with a Learning Disability: Clarissa Connors, a Medical Student…

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Although Clarissa successfully completed the didactic portion of the curriculum, she has been struggling in her clinical rotations. While patients appreciate her calm demeanor, advocacy, and “people skills,” Clarissa struggles with time management, prioritization, and finishing notes on time. She is also taking longer than her peers to complete clinical work, like chart review and writing patient notes, leaving her with little time to prepare for shelf examinations. Clarissa’s attendings notice her struggling to manage duties on clinical rotations and are worried about her self-care (e.g., sleeping, eating healthily, and maintaining mental health and well-being). Her clerkship director approaches her about these issues; however, Clarissa feels uncomfortable sharing the specifics of her disability with someone in an evaluative position. While the school had adequately addressed Clarissa’s needs in the didactic portion of the curriculum, they had never accommodated a student with learning and attention disabilities in a clinical setting and assumed that accommodations in the clinic were not reasonable. The student affairs dean and learning specialist are stumped, and without the aid of a disability resource professional who understands clinical accommodations, Clarissa fears she may fail.

Identifying Barriers from All Perspectives Perspective of the Student Perceived barrier ADHD affects executive functioning skills (e.g., disorganization, starts but does not complete tasks). Slow reading and processing speed (e.g., slow note-taking, takes more time to review charts, and write/ review patient notes, takes more time to prepare for shelf exam). Clinical environment can be hectic, noisy, and distracting, which contribute to an increased need for time to accomplish note-taking and chart review. Lack of protected time or afraid to take protected time for self-care appointments (lack of sleep, increased anxiety, feeling vulnerable). Discussing accommodations with a faculty member in an evaluative position (fear of being discriminated against due to a disability; fear of disability being misunderstood; fear of negative impact on grades, recommendations, and residency match options)

Perspective of the Medical School Perceived Barriers Student disorganization and resulting inefficiences in: managing patients, completing charts, and carrying out daily clinical duties in a timely manner. Other team members must take on additional responsibilities to make up the difference, and supervisory clinicians must stay longer to allow time for the student to complete duties. Student lack of knowledge. Since the student takes longer to complete tasks, advisory clinicians begin to wonder if the student’s knowledge base is deficient. Student lack of professionalism. Student did not approach a supervisor to acknowledge or discuss a plan to improve these deficiencies.

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Perspective of the Disability Resource Professional None – the school had not employed a DRP, and the student affairs official in charge of accommodations simply employed the recommended accommodations specified in the neuropsychological report, which only addressed didactic settings.

Deconstructing Barriers and Access Issues Starting the Process • What do you know? • What do you need to know? • How and where might you find  new information that may lead to enhanced access?

What Do You Know? • Clarissa is a third-year medical student who just started clinical clerkships. • Clarissa’s diagnoses include deficits in written and verbal language processing and ADHD. • The student received accommodations in preclinical courses, including 1.5× time on examinations in a reduced distraction environment and use of text-to-speech programs. After implementing these accommodations, her academic performance increased significantly. • Clarissa is from a low-income family and has expressed feeling a sense of “otherness” from her medical school peers. • In clinic, patients and attendings appreciate Clarissa’s calm demeanor, advocacy, and “people skills,” but she struggles with time management, prioritization, and finishing notes in a timely manner. • Clarissa takes longer than her peers to complete clinical work, leaving little time to prepare for shelf examinations. • Clerkship attendings have noticed her struggling to manage duties on clinical rotations and are worried about her self-care (e.g., sleeping, eating healthily, and maintaining mental health and well-being). • Her clerkship director approached her, but Clarissa does not feel comfortable divulging personal details of her disability to a faculty member in an evaluative position. • The institution has not designated a DRP with specific knowledge of disabilities, current assistive technologies, and clinical accommodations.

1  The Student with a Learning Disability: Clarissa Connors, a Medical Student…

What Do You Need to Know? • What are the competencies required of students in each specific clerkship? How do time management skills, meeting deadlines, and keeping up with the case load factor into these specific competencies? • Do the technical standards and/or professionalism competencies address time management skills, meeting deadlines, and/or keeping up with the case load? • Is there a policy on deceleration of clerkships? If so, who would need to join a discussion to determine if/how an exception may be made due to a diagnosed disability? • Is there a policy on protected time to ensure students in clerkships are able to tend to self-care, including medical appointments? • Are there other offices/services/resources that may be able to provide additional support to Clarissa? • Is there a way to allow her protected time to study for shelf exams? • Are there any legal mandates for accommodations in a clinical program?

 ow and Where Might You Obtain New Information that May Lead H to Enhanced Access? Potential Campus Partners • • • • • • • • •

Office of Student Affairs Office of Medical Education Clerkship Dean Clerkship Directors Wellness Team Office of Academic Support Peer tutoring/mentoring programs Office of Diversity and Inclusion Associations and organizations that work with disabled learners

Potential General Resources for the Institution and the Student • • • • •

Coalition for Disability Access in Health Science Education Near-peer institutions with medical school-specific disability providers Society for Physicians with Disabilities Twitter, searching #DocsWithDisabilities Twitter groups for disabled physicians

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Additional Discussion Questions 1. Does your program discuss clinical accommodations at the start of the program? From Chap. 4 in Disability as Diversity: Hiring a qualified disability resource professional for clinical programs is critical. Students requesting accommodations in health science programs (e.g., medicine, physical therapy, nursing, dentistry, pharmacology, occupational and physical therapy, and others) often encounter complexities that are unique to the course of study. DRPs must have a broad awareness of, and facility with, these areas. These complexities may include nuanced and variable clinical environments, restrictive or confusing technical standards, clinical competencies, and licensing requirements that result in varied thresholds of “reasonableness” when determining accommodations. Additionally, DRPs without extensive health science backgrounds will likely be unfamiliar with accommodating students in novel assessment environments such as clinical rotations, clerkships, internships, preceptorships, standardized patient exams, and objective-structured clinical examinations (OSCEs), which may make determinations about reasonable and effective accommodations in the clinical environment more challenging. In order to implement a thorough and well-informed interactive process, DRPs must develop expertise in the aforementioned clinical and legal domains and must spend considerable time learning about their respective health science programs. Had Clarissa’s school employed a qualified DRP, clinical accommodations could have been discussed immediately, considering creative and current assistive technologies. See Chap. 4 for more information on qualified DRPs in health science programs, including a job description. 2. Who is involved in the discussion about clinical accommodations? At times, schools may involve everyone in an attempt to find the right answer. Clinical faculty and administrative partners may be great resources, but it’s important to balance this involvement with the need for student privacy. From Chap. 4 in Disability as Diversity: Some schools utilize a committee approach in determining reasonable accommodations. When using a committee, a DRP should ideally lead the committee in order to reduce potential bias, to ensure a robust and fair process, and to inform best practice in the area of disability resources in health sciences. In these instances, the DRP can share the functional limitations and barriers experienced by the student, but should not share diagnostic documentation. The literature suggests a number of concerns regarding committees including the sharing of information and sensitive documentation among individuals who may, at some point, have an evaluative role. Additionally, students may be hesitant to disclose disability or request accommodations if they know that a committee of faculty or deans will be making the determination. Even when steps are taken to protect privacy, the perception that a group of individuals will review their documentation may be enough to keep students from disclosing a disability. There are additional drawbacks to using a committee approach. When faculty members are involved with the committee, having prior

1  The Student with a Learning Disability: Clarissa Connors, a Medical Student…

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knowledge of a disability can lead to unconscious bias and actions toward a student that may be expressed in more subjective evaluations or opportunities. Faculty may also unknowingly start to view the student in the role of a patient and unintentionally treat them differently. In addition to relational concerns, there may also be legal concerns about the use of a committee. For example, if a committee substitutes their clinical knowledge for the recommendations of the treating provider and fails to approve an accommodation request as a result, the required interactive process has not been followed. Committees may also meet at defined time intervals, such as monthly, which may result in delays for decision-making, which, in a fast-paced health science program, can prove costly to the student. Read more about who should be involved in the process and what that process should ideally “look like” in Chap. 4. 3. When students transition from preclinical curriculum to clerkship curriculum, is there any process to reevaluate their needs for accommodations in the clinical environment? Functional limitations look very different in varying environments. If an evaluation has not already been conducted for clinical portions of the program, a DRP or representative should do so well in advance of the student entering the clinical environment. For students who require adaptive or assistive technology, these can be “tried out” in the simulation lab, giving all parties more confidence when deploying them on the wards. From Chap. 10 in Disability as Diversity: Students with ADHD may find it difficult to compensate for the large volume of information that must be reviewed and retained in health science programs. Those with a hyperactive clinical feature may, unintentionally, struggle with professionalism expectations in these new, high-stakes settings. For these students, accommodations offer a removal of barriers in the clinical settings. In addition to accommodations, students can employ strategies that mitigate the impact of their ADHD on functioning in a clinical setting. Accommodations for ADHD include written, specific objectives or clinical expectations for a rotation, broken down by the week, with weekly feedback on progress. Feedback is best when it is delivered orally and in writing and presented as objectives met and objectives unmet with specific instruction on the steps needed in order to meet a learning objective or clinical competency [11]. Depending on the level of the student, checklists may be appropriate as a means of developmental scaffolding, while the student learns a new skill or process. Developing relationships with new teams and learning new systems or expectations, especially if these are only implied, are difficult for students with ADHD.  Therefore, minimizing change, when possible and appropriate, can help the student develop structure and allow time for the development of relationships and adjustment to both written and unwritten curriculum. For example, a student may, as an accommodation, be placed at the same hospital for multiple clerkships or rotations to avoid the added cognitive work of learning a new system (e.g., electronic medical system, protocol for students, culture). In one successful case of a resident physician with ADHD, the team utilized many of the aforementioned accommodations and added a written task list

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to be generated by the resident in the operating room, a checklist for managing logistics of the daily case load, typed preoperative evaluations to assist with presentation of patient, and time allowance by faculty for the student’s personal healthcare appointments. More information can be found in Chap. 10 regarding clinical accommodations for a myriad of disability types as well as assistive/adaptive devices. 4. Knowing that often times medical students do not realize they have a disability, and this is the first time they have ever struggled, how can your program proactively work with students to discern academic struggle from disability? Students who have disability diagnoses should be encouraged to disclose as early as possible to ensure appropriate accommodation plans can be implemented to address individual barriers. All students can be encouraged to develop strong self-­ regulation and time management skills through orientation sessions, workshops, peer tutoring programs, and faculty/academic support interventions. In addition, students should all be encouraged to discover what study skills and techniques work best for each of them in light of the increased volume and pace of complex content in health science programs. While these proactive efforts to assist students in developing learning strategies are supportive, there are an increasing number of health science students who experience barriers that may be indicative of an undiagnosed disability. The school should keep a list of referrals for testing and may wish to consider funding or subsidizing these evaluations. The school could also partner with internal programs in educational or clinical psychology, tapping into the often discounted testing done through psychology clinics. It is important to ensure students have prompt access to the assessments necessary to obtain a proper diagnosis and the corresponding documentation to inform an appropriate accommodation plan. From Chap. 6 in Disability as Diversity: Students in health science programs must develop strategies to conquer the intense workload. Some students may believe the solution is to simply work harder, even at the expense of their emotional and physical well-being. However, developing a more efficient study plan will be more effective and sustainable. Studies have demonstrated that students with SLD and ADHD do not have strong self-regulation skills and, to compensate for the barriers they face, spend more time studying than students without disabilities. Therefore, when working with students with SLD and ADHD, it is especially important to emphasize efficient study techniques and encourage the implementation of a balanced, self-regulated learning plan. Among the student population in health science programs, there is often a tendency to avoid seeking help. Students’ past experiences can impact how they value and seek support from learning or disability resource professionals. Those who have previously encountered and overcome barriers with little or no support may attempt to address issues without making use of available support systems. In addition, if a student’s impression of support services is negative due to misconceptions or previous experiences, the student may be reluctant to use these resources. In some cases, students may fear that using academic support or disability resources will further stigmatize them or worry that they will be perceived as taking advantage of the

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system. Although some health science programs include graduation competencies for developing help-seeking behaviors and maintaining self-care, much could be done to alter health science student culture to normalize and encourage help-­seeking behaviors as a critical part of professionalism. More information can be found in Chap. 6 about evidence-based learning principles and study strategies that can support students with learning disabilities and ADHD. 5. What steps can be taken to ensure faculty members employ inclusive instructional methods, which can support effective learning for students with and without disabilities? Universally designed curricula and inclusive teaching practices can proactively support students with and without learning disabilities, including those who have not yet been diagnosed. These inclusive practices provide multiple options for content acquisition which empower students to choose methods that work best for them. From Chap. 7 in Disability as Diversity: Pedagogical methods with empirically proven efficacy may still pose barriers for students with disabilities if lessons are not designed using an inclusive approach. For example, problem-based learning sessions, which require quick assessments of problems followed by time-sensitive oral responses, may present barriers for students with processing difficulty or other disabilities. The flipped classroom and problem-based learning formats can present barriers for students with learning, visual, and attentional disabilities unless accessible digital content is provided and appropriate guidance, directions, or scaffolds are implemented. As courses are designed, deliberate choices should be made to prevent barriers for students with disabilities. A “one-size-fits-all” instructional model will not work, as inflexible curricula pose barriers for students with disabilities. Deliberate, inclusive choices made by the instructor can ensure all students have full access to course content, regardless of disability. Instructors utilizing Universal Design for Education (UDE) are encouraged to use all four modalities in lessons and assignments: visual, aural, read-write, and kinesthetic. Multimodal teaching methods are designed to prevent barriers to learning from the outset and allow flexibility for a diverse group of learners. This can be done by varying the course structure (e.g., lecture, small group, thinkpair-share, hands-on activities, field work, or discussion boards), including scaffolding (e.g., posting copies of outlines/summaries or guiding groups through team assignments with a list of questions), and by providing multiple options for assimilating content (e.g., videos, podcasts, on-demand lectures, reading materials, or online resources). The use of technology is fundamental to successfully implementing UDE. UDE embraces the inclusion of a range of student assessment techniques. To be clear, the goal is not for all students to pass examinations but rather for all to have an opportunity to demonstrate their knowledge and skills without barriers. Inclusive instructors develop examinations to provide a broad range of diverse learners with varied opportunities to demonstrate learning competencies.

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Chapter 7 contains ideas for implementation of Universal Design for Education within health science curriculum, as well as specific instructional considerations to make classrooms more inclusive. 6. Medical students are hesitant to disclose for a myriad of reasons. How does your program make this a safe and protected process? See Chap. 4 in Disability as Diversity for more information. 7. How does your program consider and approach socioeconomic barriers for students? How do you work with students who present at the intersection of multiple experiences? From Chap. 3 in Disability as Diversity: Disability does not exist in a vacuum. Students with disabilities enter their health science training with diverse life experiences and may identify with minority communities based on their race, gender, sexuality, religion, and socioeconomic status. As a result, they may face barriers to academic success that can be traced beyond their disability. Therefore, supporting students with disabilities requires us to understand the students’ whole social context and the ways in which their intersecting identities shape their experience. Much like students with disabilities, students from a variety of underrepresented backgrounds face barriers to success in health science education. These barriers often occur at both individual and structural levels. For example, at an individual level, students often lack emotional support and experience social isolation and discrimination. At a structural level, they face roadblocks to accessing financial support, academic advising, mentorship, and professional socialization. Students from economically disadvantaged backgrounds similarly face social isolation, along with experiences of identity conflict. A study of working-class medical students found that these students experience a conflict between their background of origin and their new professional identities. On one hand, participants felt they had deviated from the educational expectations of their upbringing, but on the other, they continued to feel they did not belong in their new profession. One student reflecting on her experience growing up in poverty noted the isolation she experienced in her medical class: “Placed at a school attended by mostly middle-­ class students, this underprivileged experience became part of my identity, and to be different was incredibly isolating.” Chapter 3 may provide a broader context for understanding Clarissa’s struggles and the deeply internalized feelings of not fitting in. As noted in the case, Clarissa already felt “othered,” coming to medicine from an economic and academic disadvantage; when working with Clarissa, it will be important to keep this in mind. See Chap. 3 for more details. 8. What might be included in the institution’s plan to support Clarissa in her clinical rotations? An initial plan may include some of the following (Table  1.1), and Clarissa would continue to engage in an interactive dialogue to determine what, if any, additional accommodations may be necessary to best address her specific disability related barriers.

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Table 1.1  Possible accommodations to consider Perceived barrier ADHD affects executive functioning skills Slow reading and processing rates

Manifestations of encountered barrier Disorganization Starts but does not complete tasks Clinical duties take longer than peers Slow note-taking Takes more time to view charts and make determinations Preparation for shelf exam takes longer

Lack of focus Increased distractibility Contributes to disorganization New tasks arise that distract from incomplete tasks Lack of protected time Increased anxiety Lack of sleep or afraid to take Increased likelihood of protected time for self-care appointments experiencing burnout Decreased performance Clinical environment can be hectic and noisy

Discussing accommodations with a faculty member in an evaluative position

Increased anxiety Fear of being discriminated against due to a disability Fear of negative impact on grades

Possible accommodation(s) The 12-month clerkship program was decelerated and executed over 13 months, giving Clarissa almost 4 weeks of time to prepare for the clerkship and study for shelf exams Student was allowed to use HIPAA-compliant speech-to-text dictation software to take notes For use at home when studying for shelf exam, student was trained to use text-to-speech software with a software extension that included a medical dictionary Protected time to study for shelf exams Student was allowed to wear noise-cancelling headphones when writing notes and reports in the clinic and on the wards Student was provided a reduced distraction space to do clinical work whenever possible (i.e., empty exam or call room, working on a laptop that can be moved, etc.) The policy for protected time was reviewed with the student, and the student provided a list of all scheduled medical appointments two weeks in advance of any absence Decelerated clerkship schedule; the 12-month program was given over 13 months A qualified DRP would have been able to engage in the interactive process with the student while looping in relevant nonevaluative stakeholders (giving them only relevant information on a need-to-know basis) to determine a viable accommodation plan

References and Resources Chapters 3, 4, 6, 7 and 10 from the book Disability as diversity: a guidebook for inclusion in medicine, nursing, and the health professions. Springer Nature. September 2020. 1. Allsopp DH, Minskoff EH, Bolt L. Individualized course-specific strategy instruction for college students with learning disabilities and ADHD: lessons learned from a model demonstration project. Learn Disabil Res Pract. 2005;20(2):103–18. 2. Barga NK.  Students with learning disabilities in education: managing a disability. J Learn Disabil. 1996;29(4):413–21. 3. Denhart H. Deconstructing barriers: perceptions of students labeled with learning disabilities in higher education. J Learn Disabil. 2008;41(6):483–97.

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4. Dyrbye LN, Eacker A, Durning SJ, Brazeau C, Moutier C, Massie FS, et al. The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout. Acad Med. 2015;90(7):961–9. 5. Fitzsimons MG, Brookman JC, Arnholz SH, Baker K. Attention-deficit/hyperactivity disorder and successful completion of anesthesia residency: a case report. Acad Med. 2016;91(2):210–4. 6. Fuller M, Healey M, Bradley A, Hall T. Barriers to learning: a systematic study of the experience of disabled students in one university. Stud High Educ. 2004;29(3):303–18. 7. Hmelo-Silver C, Duncan R, Chinn C.  Scaffolding and achievement in problem-based and inquiry learning: a response to Kirschner, Sweller, and Clark (2006). Educ Psychol. 2007;42(2):99–107. 8. Jain NR, Meeks LM. Privacy, disability, and health science students. Disabil Compliance High Educ. 2017;22(7):7. 9. Kenney MJ, Jain NR, Meeks LM, Laird-Metke E, Hori J, McGough JD. Learning in the digital age: assistive technology and electronic access. In: The guide to assisting students with disabilities: equal access in health science and professional education. New York: Springer; 2016. p. 119–40. 10. Ketterlin-Geller LR, Johnstone C. Accommodations and universal design: supporting access to assessments in higher education. J Postsecondary Educ Disabil. 2006;19(2):163–72. 11. Kumar K. A journey towards creating an inclusive classroom: how universal design for learning has transformed my teaching. Transform Dialogues Teach Learn J. 2010;4(2):1–5. 12. Leyser Y, Greenberger L. College students with disabilities in teacher education: faculty attitudes and practices. Eur J Spec Needs Educ. 2008;23(3):237–51. 13. Laird-Metke E, Serrantino J, Culley JL. The process for determining disability accommodations. In: The guide to assisting students with disabilities: equal access in health science and professional education. New York: Springer; 2015. p. 33. 14. Pliner SM, Johnson JR. Historical, theoretical, and foundational principles of universal instructional design in higher education. Equity Excell Educ. 2004;37(2):105–13. 15. Meeks LM, Jain NR. The guide to assisting students with disabilities: equal access in health science and professional education. New York: Springer; 2015. 16. Meeks LM, Jain NR.  Accommodating standardized patient exams: the OSCEs. Disabil Compliance High Educ. 2016a;22(4):7. 17. Meeks LM, Jain NR.  Accommodating students on anatomy and other lab practical exams. Disabil Compliance High Educ. 2017;23(3):1–7. 18. Meeks LM, Jain NR. Helping faculty find the balance: communicating with students with disabilities. Disabil Compliance High Educ. 2016b;21(9):7. 19. Murray JF, Meeks LM.  Support medical students with psychological disabilities. Disabil Compliance High Educ. 2016;21(12):7–7. 20. Norman K, Caseau D, Stefanich GP. Teaching students with disabilities in inclusive science classrooms: survey results. Sci Educ. 1998;82(2):127–46. 21. Patwari R, Ferro-Lusk M, Finley E, Meeks LM.  Using a diagnostic OSCE to discern deficit from disability in struggling students. Acad Med. 2020; https://doi.org/10.1097/ ACM.0000000000003421. 22. Reis SM, Neu TW. Factors involved in the academic success of high ability university students with learning disabilities. J Second Gift Educ. 1994;5(3):60–74. 23. Rose DH, Harbour WS, Johnston CS, Daley SG, Abarbanell L. Universal design for learning in postsecondary education: reflections on principles and their application. J Postsecondary Educ Disabil. 2006;19(2):135–51. 24. Scott SS, McGuire JM, Foley TE. Universal design for instruction: a framework for anticipating and responding to disability and other diverse learning needs in the college classroom. Equity Excell Educ. 2010;36(1):40–9. 25. Scott SS, Mcguire JM, Shaw SF. Universal design for instruction: a new paradigm for adult instruction in postsecondary education. Remedial Spec Educ. 2003;24(6):369–79.

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26. Serrantino J, Meeks LM, Jain NR, Clifford GC, Brown JT. Accommodations in didactic, lab, and clinical settings. In: The guide to assisting students with disabilities: Equal access in health science and professional education. New York: Springer; 2015. p. 59–88. 27. Serrantino J, Hori J. Memory, retention, and retrieval: using Livescribe smartpen as an accommodation. Disabil Compliance High Educ. 2017;23(2):7–7. 28. Serrantino J. Accommodations in the clinical setting: the what, who, where, how, and why. Disabil Compliance High Educ. 2016;22(2):7–7. 29. Silver P, Bourke A, Strehorn KC.  Universal instructional Design in Higher Education: an approach for inclusion. Equity Excell Educ. 1998;31(2):47–51. 30. Stergiopoulos E, Fernando O, Martimianakis MA. “Being on both sides”: Canadian medical students’ experiences with disability, the hidden curriculum, and professional identity construction. Acad Med. 2018;93(10):1550–9. 31. Sullivan L, Meeks LM.  Big solutions for small groups in health science programs. Disabil Compliance High Educ. 2018;23(8):1–7. 32. Vogan CL, McKimm J, Da Silva AL, Grant A. Twelve tips for providing effective student support in undergraduate medical education. Med Teach. 2014;36(6):480–5. 33. Winter RI, Patel R, Norman RI.  A qualitative exploration of the help-seeking behaviors of students who experience psychological distress around assessment at medical school. Acad Psychiatry. 2017;41(4):477–85. 34. Zimmerman BJ. Investigating self-regulation and motivation: historical background, methodological developments, and future prospects. Am Educ Res J. 2008;45(1):166–83.

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The Student with a Physical Disability: Tammy Thomas, a Clinical Year Medical Student with Quadriplegia Christopher D. Connolly, Maya M. Hammoud, and Charlotte H. O’Connor

Case History Tammy is a C6-C7 complete quadriplegic who uses a power wheelchair, functions independently with minimal assistance, and has limited hand dexterity, core balance, and use of her lower extremities. Upon acceptance to medical school, Tammy contacted the school’s disability resource professional (DRP) to discuss technical standards and accommodations but discovered that the medical school uses the undergraduate campus office. While they agreed on accommodations for the preclinical years, Tammy felt uneasy as she believes the greatest barriers will arise in clerkship years, specifically in procedural-­ based clerkships such as surgery and obstetrics/gynecology (Ob/Gyn); nevertheless, they decide to delay addressing these once Tammy has time to navigate and assess the clinical environment on other clerkships. In her first year of medical school, Tammy worked with an occupational therapist and medical school faculty to practice physical exam skills. Despite Tammy’s limitations, she could perform the majority of physical exam skills with modified equipment and additional time. As the clinical year approaches, Tammy becomes increasingly nervous. She meets with the DRP again to discuss accommodations. vThough the DRP is experienced in providing didactic accommodations to medical students with disabilities, she admits that she has minimal experience working with clinical students who are C. D. Connolly (*) · M. M. Hammoud University of Michigan Medical School, Ann Arbor, MI, USA e-mail: [email protected]; [email protected] C. H. O’Connor Office of Medical Student Education, University of Michigan Medical School, Ann Arbor, MI, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_2

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wheelchair users. She suggests that Tammy contact a physician who is a wheelchair user and develop a repertoire and then inquire about how they navigated medical school and how to respond to patients or preceptor concerns. She also suggests personally contacting clerkship directors. While Tammy appreciates this meeting  with the DRP, she still has questions about the barriers she may encounter on the clerkships and feels like the burden of figuring out how to navigate this space and having to personally contact the clerkship directors has placed her in an awkward position. Based on conversations she has had with other students, she is aware that some procedures may be difficult for her to accomplish without accommodations. She is unsure of the specific procedures that may pose barriers to her and is becoming increasingly concerned. In this case, Tammy decides to contact the Ob/Gyn and surgical clerkship directors directly. She explains her known limitations and the Oob/Ggyn clerkship director offers to schedule a meeting with her; she was experienced working with students with disabilities and had some creative ideas. When they meet, the clerkship director shows Tammy the operating room  and explains in detail the processes she will be required to perform on the clerkship. This experience leads to the identification of adaptive tools to assist Tammy in the Ob/Gyn clerkship. The clerkship director ensures Tammy that these items will be available to her.In addition, the clerkship director encourages Tammy to introduce herself through email to the surgical and Ob/Gyn residents and attendings to inform them of her needs and to stay in touch with them should she have further concerns. Tammy offers to answer any questions the residents or attending physicians may have, opening the door for ongoing productive dialogue.

Perspectives Barriers from the perspective of the student Feeling overwhelmed by the increased technical nature of Ob/Gyn and surgery Lack of accessibility at outpatient clinics The additional time it takes to complete professional tasks due to the disability (performing physical exams, writing notes, etc.) The additional time it takes to complete everyday tasks due to the disability (using the bathroom, etc.) Concerns that physical limitations will prevent participating in physical exams, pap smears, vaginal deliveries, and C-sections Feelings of isolation as the only person in the program with an obvious physical disability As a newly injured student, she is still learning self-advocacy and feels an extra burden to have to navigate clinical accommodations independently. Barriers from the perspective of the faculty Wheelchair accessibility barriers in clinics Ensuring the safe modification of procedures and physical exams Identifying which procedures Tammy can complete independently and supporting her development in these procedures

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 arriers from the Perspective of the Disability B Resource Professional Do the program’s technical standards support accommodations/modifications? What are the clinical program requirements? What are the physical barriers in the various clinical sites? Would some specific services provide better learning experiences than others? What assistive technology will the student require? Who can help answer these questions?

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know?

Tammy is a C6-C7 complete quadriplegic. She uses a power wheelchair. She functions independently with minimal assistance. She has limited hand dexterity, core balance, and use of her lower extremities. The DRP is unfamililar with clinical accommodations.

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What Do We Need to Know? How do our institution’s technical standards address motor function? What are the competencies for the rotations? How will Tammy perform physical exam skills? How will she accomplish procedures in surgery and Ob/Gyn (e.g., scrubbing, gloving, and gowning)? Are all clinical settings accessible to a power wheelchair? Is there a liaison in the medical school who can work with the Office of Disability Services to coordinate accommodations?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? Technical standards Clerkship directors Occupational therapists Physical medicine and rehabilitation physicians Physicians who are wheelchair users Disability resource professionals at other medical schools Professional organizations (e.g., AHEAD, Coalition for Disability Access in Health Science Education) Experienced colleagues at other medical schools Assistive technology and accessibility experts

Discussion Questions 1. How would your institution’s technical standards impact Tammy? 2. As a DRP, would you have the knowledge to go through the interactive process with Tammy? How would you prepare for this meeting? 3. Who is responsible for contacting the Clerkship Director initially? What is the best way to determine the specific needs of the student with a disability? 4. How would you determine appropriate and reasonable accommodations? 5. What reasonable accommodations could you make for Tammy? 6. How would you implement the accommodations? Who would communicate and coordinate accommodations?

Summary and Guidance In Tammy’s case, it was fortunate that the clerkship directors were willing and able to assist in the areas in which the DRP was not knowledgeable. However, it is not reasonable to rely on clinical staff to determine accommodations in isolation; it is

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the DRP’s responsibility to be knowledgeable of clinical requirements and to use this knowledge to guide the interactive process with students. Chapter 4 of Disability as Diversity details the expertise required of a well-qualified DRP. For the Guidance of the DRP with Limited Knowledge While some medical schools employ their own disability resource professionals, many others rely on an Office of Disability Services that serves their entire campus. Persons in a centralized office may not be familiar with clinical program requirements, as noted in Chap. 4 of Disability as Diversity [1]. If this is the case, it is necessary for the DRP to become familiar with the medical school’s technical standards and to work closely with its other personnel, including faculty, clerkship directors, occupational therapists, physical medicine and rehabilitation physicians, and clinical staff and/or physicians who are wheelchair users. If the DRP is not familiar with medical education, it may be necessary for them to visit clinical sites to evaluate accessibility, to see the physical layout of the clinical settings, and to observe others perform the required competencies prior to recommending accommodations. The DRP should also become familiar with the specific services in each clerkship and, with faculty and the student, determine which would provide the optimal learning environment. With this knowledge and the student’s input, the DRP should be able to determine appropriate clinical sites and accommodations. Through professional organizations and other medical schools, the DRP may connect with others experienced in working with medical students who have quadriplegia. In addition,  while each person has unique needs and abilities, learning about creative accommodations other have employed may provide the spark required to develop an accommodation not previously considered. Assistive technology continues to improve and expand. The DRP should be aware of current offerings and stay abreast of new developments in this arena through continuing education, professional organizations, and connecting with any campus groups involved with accessibility and technology. Guidance for the DRP with Clinical Accommodation Experience DRPs with experience working with health sciences students in clinical settings engage with the student to determine accommodations through the interactive process. Given that seasoned DRPs are familiar with the technical standards, maintain partnerships with key clinical staff, and will have visited clinical sites for firsthand knowledge of possible barriers for students with disabilities, this process will be well-informed. While it is crucial for DRPs to be aware of the demands of each clerkship, familiarity with the Ob/Gyn and surgery clerkships is also critical to determining accommodations for the student with a physical disability, such as Tammy. Chapter 5 in Disability as Diversity notes that these particular clerkships provide challenges as

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they require specific procedural skills, frequently involving urgency, physical and emotional intensity, and a demanding schedule of long days. After the initial meeting between the DRP and the student, any remaining questions and concerns should be directed to the Clerkship Director. If necessary, the student may visit the clinical setting to observe the conditions under which they will be required to work during their clerkships. Chapter 10 in Disability as Diversity discusses a variety of clinical accommodations, including assistive devices.

Potential Clinical Accommodations Before clerkship During clerkship Prioritize placing student at most accessible clinics Allow the student additional time to complete clinical responsibilities Use of the following adaptive technology: Collaborate with an occupational therapist,  •  Voice-dictation software for entering experienced disability resource professional, and notes and orders medical school faculty to practice physical exam  • Cardiology stethoscope with modified and procedure skills handle (Image 2.1) to help student hold stethoscope  • Panoptic ophthalmoscope/otoscope  • Reflex hammer with modified handle to help student hold a reflex hammer  • “Oval-8 Finger Splints” to keep fingers extended for Ob/Gyn physical exam maneuvers Consider placing surgery and Ob/Gyn rotations at Establish a point person to assist a student the end of a student’s clinical rotation schedule with some aspects of physical exams and procedures when time permits Allow protected time for a student to attend to personal care needs Provide regular feedback sessions to discuss her strengths and areas for development

Image 2.1  3D-printed cardiology stethoscope handle

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A cardiology stethoscope handle allows individuals with limited dexterity to obtain an improved grasp of a cardiology stethoscope. The cardiology stethoscope handle shown flips over both the bell and diaphragm of a cardiology stethoscope to allow use of either side during auscultation.

References and Resources Chapters 4, 5, and 10 from Disability as diversity: a guidebook for inclusion in medicine, nursing and the health professions. Springer Nature. September 2020. 1. Meeks L, Jain NR. The guide to assisting students with disabilities: equal access in health science and professional education. New York: Springer; 2016. 2. Connolly C, Yoon S.  Cardiology stethoscope handle. Cardiology Stethoscope Handle, University of Michigan. 2019. umich.flintbox.com/?embed=true#technolog ies/26397472-171f-46ab-83c4-a1b0fe886d1b. 3. Kenney MJ, Jain NR, Meeks LM, Laird-Metke E, Hori J, McGough JD. Learning in the digital age: assistive technology and electronic access. In: Meeks LM, Jain NR, editors. The guide to assisting students with disabilities. New York: Springer; 2016. p. 119–40. 4. Serrantino J, Meeks LM, Jain NR, Clifford GC, Brown JT. Accommodations in didactic, lab, and clinical settings. In: Meeks LM, Jain NR, editors. The guide to assisting students with disabilities: equal access in health science and professional education. 1st ed. New York: Springer; 2016. p. 59–88.

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The Student with a Sensory Disability: Conrad Barker, a Rising Third-Year Medical Student with Hearing Loss Michael S. Argenyi, Alicia Booth, and Christine Low

History Conrad Barker is a rising third-year medical student, who happens to have hearing loss. From a small town, he was diagnosed with profound hearing loss (per audiometry) as an infant and learned American Sign Language (ASL) as a young child. All of his family members are hearing, and the family used both ASL and spoken English in the home. During this time, Conrad’s speech recognition scores were about 4% on standard tests, even with hearing aids. His adept speechreading skills and intelligible speech reinforced his parent’s decision to mainstream Conrad into the local public elementary school. The school district and his disability caseworker, assigned to evaluate his individual education plan, determined that in lieu of an ASL interpreter, they would provide front row seating, closed captioned videos, and speech therapy. With a small student-teacher ratio of 15:1 in elementary school and middle school, Conrad did well until vocabulary deficits and diminished class participation surfaced in eighth grade; in ninth grade, he was provided ASL interpreters, and his academic performance and social participation improved over 1 year. Conrad graduated with a 3.74 GPA, 4 years’ participation on the track team, and budding interest in medical school. His hearing loss levels and audiometry remained at baseline. M. S. Argenyi (*) Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA e-mail: [email protected] A. Booth Designated Interpreters LLC, New York, NY, USA e-mail: [email protected] C. Low Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_3

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For accommodations during his undergraduate program, Conrad had ASL interpreters and/or Computer-Aided Real-time Transcription (CART, a service where a captionist transcribes verbatim classroom dialogue while Conrad follows simultaneously on a laptop) depending on his needs. He solidified his interest in medicine through shadowing a family medicine physician, volunteering at a food bank, and joining the pre-medicine interest group on campus. Conrad continued to perform well, graduating with a 3.9 GPA. He tested well on the MCAT and was accepted to medical school. After acceptance, but prior to matriculation, Conrad received his first cochlear implant, experiencing improved sound awareness and limited ability to have conversations on the phone (word recognition scores increased to around 50%). He began medical school as the school’s first matriculating deaf student. The medical school designated administrators and faculty from the medical school to evaluate all matriculants’ ability to meet the technical standards. This technical standards committee, as they were called, additionally evaluated any requests for disability accommodations. The disability professional from the undergraduate campus of the medical school was not involved in the process. The committee decided that Conrad would receive CART services for the first 2 years of lectures and small group discussions, but would not receive accommodations in the clinical setting, asserting that sign language interpreting and CART are a fundamental alteration of the program and a financial burden to the program. Conrad successfully passed each didactic course. During his second-year outpatient clinical experience, Conrad asked for an ASL interpreter. He felt this would make the patient experience and conversation more seamless. He also suggested that ASL interpreting would give him better access to incidental clinical knowledge and make the process of seeing patients more efficient. The technical standards committee granted Conrad a local ASL interpreting team, who had no specialization in clinical medicine. Conrad’s supervising physician was pleased with his clinical and rapport-building skills and was surprised that the interpreting process did not cause clinical delays. Conrad validated that he was able to have unhindered conversations with patients and fuller access to incidental knowledge with the community interpreters but noted they were not experienced with medical terminology and clinical protocols and were sometimes unable or unwilling to adapt to Conrad’s preferences in handling technical, linguistic, and emotional nuances during clinical encounters. While this has worked in an outpatient, 1 day a week clinical setting, Conrad is concerned about how he will communicate with the team and scale the interpreter’s knowledge of medicine enough to handle the fast-paced setting in the hospital. He predicts that the inpatient environment will be much different than the environment in the clinic. Now at the end of second year anticipating entry into the clerkships full time, Conrad meets with the technical standards committee to discuss evolving accommodation needs. In particular, both Conrad and the committee are concerned about full access during the surgical clerkship and are concerned about adding

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interpreters (who often work in teams of 2) given space constraints, confidentiality, and attendings’ perceptions of interference by the interpreting team. Without the advice of the specialized disability resources professional (DRP) (the undergraduate disability office does not understand the medical school curriculum), the medical school technical standards committee gives Conrad the option to waive the operating room (OR) component for the surgical clerkship (which negates the technical standards) instead having Conrad spend his time in outpatient procedural clinics and OR simulation labs. Conrad, through networking with other deaf healthcare professionals through the Association for Medical Professionals with Hearing Loss (AMPHL), had heard about the designated interpreter (DI) model, a sign language interpreter that specializes in adapting to the advanced linguistic terminology and unique work environment and collaborates on interpreting features preferred by that particular deaf individual. He wonders if the DI model would benefit his ability to maneuver the operating room and clinical space more fluently. He is also concerned that the school is removing a valuable portion of his education, robbing him of a meaningful and equal experience to that of his peers. Given the hesitation of the committee, he is concerned about asking for another change in accommodations. He believes the school just wants this “to go away.”

Perspectives Barriers from the Perspective of the Student Lack of disability support: lack of a disability resources professional who specializes in clinical programs, lack of disability informed accommodation decision-making on the technical standards committee Access to conversations: use of surgical masks (diminish student’s ability to speechread and receive facial expression cues) Draw on cognitive and visual load: speechreading and/or watching the interpreter while simultaneously attending to surgical site (eyes can only be one place at a time) Discerning difference between similar sounding words: use of highly specialized anatomical vocabulary (e.g., urology and neurology sound and look very alike; thoracotomy and thoracostomy are very different procedures) “Othering” and marginalization balanced with need: conflict between desire to be treated like any other medical student and complete surgical rotation for the experience and exposure but also cognizant of likely challenges in the OR and the desire of the school to simply “waive” the experience Lack of encouragement and appropriate career counseling: implicit and explicit discouragement to pursue surgical specialty as a career option from friends, colleagues, and supervising physicians Professional and personal networking: lost opportunities for peer and professional networking given ineffective accommodations in clinic and lack of accommodation for social events such as lunch breaks with residents and other students, medical school barbeques, and special interest groups such as the Family Medicine Interest Group (diminished extracurricular and career opportunities) Potential retaliation: concern about repercussions of advocating for the necessary accommodations

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Barriers from the Perspective of the Medical School Legal compliance: concern about whether the medical school is maintaining compliance with the Health Information Portability and Accountability Act (HIPAA) when CART captionists and ASL interpreters are translating clinical information and have access to PHI Patient privacy: concern that patients will report loss of privacy during clinical encounters with the addition of nonclinical support staff Integrity of technical standards: question of whether the student is unable to meet the technical standards of the program Undifferentiated medical graduate: conflict between desire for all students to be undifferentiated graduates and concern that Conrad will not be able to pursue certain specialties OR-specific concerns: concern for patient safety in the OR related to potential delays in Conrad following directives and additional bodies in a small physical space requiring sterile zones Integration of the learner with disability into healthcare settings: inability to educate all precepting attendings and other healthcare staff or prevent all potential bias or discrimination based on disability Lack of disability services experience: isolation from the main campus disability services representatives and novelty of a first-time matriculant with hearing loss, including unfamiliarity with creative and innovative methods for mastering specific competencies or accessing overhead, telephone, and in-person information in diverse healthcare settings Ability to function in fast-paced clinical settings: concern about Conrad’s ability to respond and communicate in time-sensitive training clerkships such as OB/GYN and emergency medicine

Barriers from the Perspective of the Designated Interpreter Asserting value: potential resistance from medical school regarding the need for specialized interpreters, including concern over cost Permission for preparation and outreach: conducting early outreach to clerkship directors, attending physicians and surgeons, and key hospital staff that allows support staff to familiarize them with best practices with learners with hearing loss and the role of an interpreter. Early access to rotation schedule and curriculum to prepare and enhance the interpreting process Unconventional staffing needs and coverage: interpreters may not be able or willing to work early, extended, night, weekend, and on-call hours Clinical access and credentialing: hospital credentialing (immunizations, HIPAA, background checks, badging and door entry access, scrub access, and other potential needs) is required in order to integrate the DI into the learner’s healthcare team Visibility in settings requiring masks: speechreading interpreters may be necessary for full access in OR settings, which requires coordination and permission with hospital leadership and OR staff to find suitable alternatives to traditional surgical masks Identifying learner needs: the DI needs to work with the learner to determine best fit of single or multiple modalities, such as simultaneous CART and ASL interpretation, for each clinical setting to best provide communication access Proximity to auditory information: difficulty in hearing relevant information, such as within the sterile zone in the OR and around medical equipment Access to auxiliary technology: ability and willingness of support staff to use microphones or other technology to enhance access to auditory information Protection of support staff: advocacy includes safety of any support staff, including formal training on sterile zones, personal protection equipment, blood-borne infections, and exposure to radiation among other topics

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 arriers from the Perspective of the Disability Resource B Professional (DRP) Approval of accommodations: conflicting feeling about decisions made by a large committee unfamiliar with clinical accommodations Inexperience with requirements of medical training: lack of understanding regarding core competencies/essential requirements for the medical curriculum and the school’s technical standards Financial management: lack of understanding about how to fund accommodations and what is considered reasonable Legal compliance: concern about rejection of accommodation requests and the legal implications Framing success: difficulty explaining how an individual with hearing loss could practice medicine, given little knowledge of physicians who are deaf or hard of hearing

Deconstructing the Barriers and Access Issues Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know? Conrad is entering the clinical third and fourth years portion of medical school. Conrad has benefited from both CART and ASL interpreters during college and his second year of medical school. Conrad is an adult learner who is proactive and knowledgeable about his accommodation needs and has identified other deaf and hard of hearing physicians and trainees, and associations, as potential resources. Conrad successfully passed his first 2 years of medical school lectures and outpatient clinic. Conrad has identified that ASL interpreters are more adaptable for his clinical practice. Conrad is interested in exploring the designated interpreter model. Conrad has a cochlear implant with some improvement in word recognition scores. Conrad has speechreading skills and intelligible speech. This is the school’s first experience matriculating a deaf student.

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What Do We Need to Know? Are there successful deaf and hard of hearing physicians who have completed medical education, including surgical training? Is there emerging technology that might enhance access? What equipment and capacity does the OR already have to accommodate technological accommodations, such as infrared capacity for remote captioning, robust wireless streaming, or monitors for displaying captioning? Is a technology specialist available, particularly if issues arise during clinical rotations? How can we educate the surgical team and staff to fully integrate a deaf or hard of hearing student? Is there a process for reevaluating accommodations as the learner enters the clinical setting? How is career counseling conducted? Will Conrad have equal support for all specialties if he is well-qualified? Is there a clear process for the allocation of accommodation funding? Who has knowledge regarding the medical curriculum and nuances of clinical training and can serve as the medical school’s designated point of contact for disability resources, interpreters and other support staff? What are the core competencies and essential requirements required for all students in the OR clerkship? Has the technical standards committee created a precedent to fundamentally alter the program by suggesting Conrad be excused from the OR component of his surgery clerkship? How can institutional disability resource professionals work with the medical school faculty and technical standards committee to help them understand that they are required by law to provide reasonable accommodations for learners with disabilities throughout all components of the program? What clerkships might require extensive planning to provide effective accommodations? Would a simulation lab be effective in determining the correct combination of accommodations before Conrad begins his rotations in the OR and other clerkships?

Where Can We Find the Information Needed?

Collaboration with clerkship directors to review core content and core competencies linked to the clerkship A review of previous accommodations within the school to see if any are applicable Site visit to the floors and OR to review the spaces, staffing, and the current capacity for technology

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Outreach to colleagues at other schools with experience accommodating students with similar needs Outreach to national organizations such as the National Deaf Center, Association for Medical Professionals with Hearing Loss, and Coalition for Disability Access in Health Science Education Meeting with the student to review the applicability of previously successful accommodations Institutional and medical school administration regarding funding, potentially contacting human resources or other institutional offices to discuss funding mechanisms Institutional Office of the General Counsel to determine legal rights and responsibilities

Discussion Questions 1. What are the benefits of Conrad completing a standard surgical rotation like all of his peers? 2. What role do the technical standards play in determining reasonable accommodations? From Chap.9 in Disability as Diversity: The term technical standards refers to all nonacademic admission criteria that are essential to participation in the program. Screening out someone with a disability occurs when a program applies a technical standard to a program’s admission standard that is not grounded in actual competencies required by the health professional education program, accrediting body, or that does not consider potential accommodations for meeting the standard. Advances in technologies, recent case law, and a growing cohort of health science professionals with disabilities in practice have challenged programs to rethink their technical standards. Modern technologies such as high-frequency audio and visual output stethoscopes, standing wheelchairs, and voice-to-text technologies allow individuals with disabilities to perform the same tasks asked of their peers with equal competence. By focusing on the final competency, not the method a student uses, programs measure the “what” and not the “how.” The use of functional technical standards can assist in removing barriers that prevent students with disabilities from entering into health professional education programs and then into health professions, improving the diversity of the healthcare professional workforce. See more information on technical standards on Chap. 9. 3. What is the recommended process for determining effective accommodations? From Chap. 4 in Disability as Diversity:

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Students requesting accommodations in health science programs often encounter complexities that are unique to the course of study. Therefore, DRPs must have a broad awareness of, and facility with, these areas. Complexities may include nuanced and variable clinical environments, restrictive or confusing technical standards, clinical competencies, and licensing requirements that result in varied thresholds of “reasonableness” when determining accommodations. In the clinical domain, as opposed to other environments, reasonable accommodations must not only consider program standards but must also take patient safety into consideration. In addition, clinical accommodations must not alter the essential functions of a course or program. The key contact in the accommodation process is ideally a neutral DRP. When a program does not have a DRP, the key contact should be someone who does not serve in an evaluative or academic decision-making role. To remove bias and the potential for discrimination, individuals who hold an evaluative faculty position, who serve in the role of admissions or student affairs dean, or who function as the director of the program should not be the points of contact for an accommodation request. 4. What is the process at your institution for reevaluating accommodations as the student progresses through their academic program? From Chap. 10 in Disability as Diversity: Functional limitations look very different in varying environments. If an evaluation has not already been conducted for clinical portions of the program, a disability resource professional (DRP) or representative should do so well in advance of the student entering the clinical environment. For students who require adaptive or assistive technology, these can be “tried out” in the simulation lab, giving all parties more confidence when deploying them on the wards. 5. How might accommodation need change for a student who: (a) Does not know ASL? (b) Relies on both receptive (input) and expressive (output) ASL (i.e., does not use spoken English)? (c) Develops headaches after viewing the CART transcript for several hours? 6. What is your institution’s process and resources, internal and external, for vetting ASL interpreters? What outside resources exist to vet interpreters? 7. What is your institution’s process for onboarding ASL interpreters, especially in the clinical setting? 8. What are the benefits of having multiple modalities (CART and ASL), such as the operating room setting? 9. What are the expectations of using a mask in the OR or with patients on isolation at each participating hospital? (a) What is the ability to procure specialized equipment (e.g., clear masks or Stryker helmets) as needed? (b) Who has authority at each healthcare setting to make decisions about mask use? 10. What are some successful accommodations for deaf and hard of hearing students in the operating room?

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From Chap. 10 in Disability as Diversity: Participants, in collaboration with the CART provider, will need to assess the OR to determine optimal placement and ensure the DHH person can see the surgical team, patient, and text without violating sterility. Options have included transmitting text to a screen in a transparent sterile sleeve or to a large mounted monitor. The transmitting microphone must be placed with consideration; one solution has been to ask the primary surgeon (or another designated educator) to wear the microphone under their sterile gown. A variety of interpreters can also be utilized. The OR team should consider where interpreters can be best positioned so that they can hear conversations while being seen clearly by the DHH person. They might stand behind the primary surgeon so that the DHH person can easily shift gaze from the surgeon to the interpreter, or they might rotate around the room while remaining mindful of sterile spaces. Specialized equipment can also be helpful. Traditional surgical masks block visible mouth movements, blocking a DHH individual that lip-reads from fully accessing communication. To address this barrier, the interpreters for one resident physician in a surgical specialty used Stryker orthopedic hood masks, which have a clear face shield so that people can view the mouth movements and expressions of the clinical team and interpreters.

Summary Conrad is already familiar with other deaf and hard of hearing physicians through AMPHL, and a truly interactive process would involve his eagerness to bring his growing network’s resources to the committee’s table. These successful role models can provide Conrad and the committee with specific recommendations for accommodations, including in the operating room, as well as career counseling with guidance on how to approach residency programs in a way that frames hearing loss positively. Furthermore, this case highlights the critical importance of the involvement of disability resource professional (DRP) and support service providers such as DIs and CART providers. The American Association of Medical Colleges recommends that medical schools have an integrated DRP, who is highly familiar with the requirements of each component of training as well as how the Americans with Disability Act (ADA) provisions apply to implementing technical standards. The DRP would lead a rigorous interactive accommodation process, updating it as a student moves through various phases of the program. In this case, the DSP would be able to predict that Conrad’s needs may differ between the outpatient longitudinal setting and his surgical rotation and that he would need continuous services since he needed access in the lecture hall. Conrad, the DSP, and the medical school committee could discuss possibilities, including an FM system for his cochlear implants, remote or mobile CART services, and a DI team. Given Conrad’s modest success with cochlear implants and ease with ASL, we would recommend to the committee that Conrad start with DIs during his clinical rotations and consider the

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addition or substitution of CART or fusion ASL/CART as necessary. The interpreters could augment their ability to provide access, by providing attending physicians with Bluetooth microphones, thereby hearing from a distance, especially during in the operating room or during inpatient rounds. Ideally, the interpreting team would have a lead interpreter, who would organize scheduling and compliance with medical clearance and badging and be a liaison among the medical school, healthcare settings, and the learner. The interpreter’s role as communication specialist may include other tasks outside of the traditional community interpreting paradigm to ensure inclusivity and equity in the learning process.

Clinical Accommodation Chart from Chap. 10 Table 10.5  Common accommodations for deaf and hard of hearing healthcare students and trainees, education settings in which they are often used, and formal certifications or qualifications that may be held by providers of each accommodation Accommodation Computer-Aided Real-time Transcription (CART)

Setting Lectures, didactic sessions, small-group meetings. Has been used in the operating room

Note-taking services Sign language and/or oral interpretation services

Didactic Wide range: can include large-group lectures and one-on-one interactions

Cued English transliterator services

Wide range: can include large-group lectures and one-on-one interactions Clinical settings requiring droplet or respiratory isolation or sterile precautions for procedures

Transparent surgical masks

Commonly recognized certifications or qualifications Certification through the National Court Reporters Association (NCRA), which can include Certified Realtime Reporter (CRR), Certified Realtime Captioner (CRC) None Certifications exist at national (e.g., Registry of Interpreters for the Deaf – RID) and state levels (e.g., Board for the Evaluation of Interpreters – BEI) Certification is provided by the Testing, Evaluation, and Certification Unit (TECUnit) Food and Drug Administration approval may be supportive

A Note About Legal Determinations From Chap. 9 in Disability as Diversity: Two cases in particular highlight the legislative mandates of inclusion of DHOH trainees: Argenyi vs. Creighton and Featherstone vs. Pacific Northwest University of Health Sciences. In Argenyi vs. Creighton, a medical student with hearing impairment was denied auxiliary aids and services  – interpreters and CART.  The jury returned a verdict in favor of the plaintiff with respect to two issues. They ruled that the defendant discriminated against the plaintiff based on his disability by failing to

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provide him with necessary auxiliary aids and services during his first 2 years of medical school and that it would not have been an undue burden on the school for it to provide such auxiliary aids and services. The cost was approximately 200 k. In Featherstone vs. Pacific Northwest University of Health Sciences, a deaf student was denied auxiliary aids and services, interpreters and CART.  The university deferred the student’s admission for a year and then withdrew his acceptance altogether citing concerns for patient safety. The court granted a preliminary injunction “requiring PNWU to matriculate Plaintiff with his classmates on August 4, 2014, with the reasonable accommodations requested” and ruled that it was not an undue financial burden for the school to provide interpreters, despite the school being only a year old. In both these cases, the courts favored the students’ inclusion, “in part due to the expansion of accessible technology and accommodations in use nationally and the prior successes of clinicians with hearing loss.”

References and Resources Chapter 2, 4, 7, 9, 10 from the book Disability as diversity: a guidebook for inclusion in medicine, nursing, and the health professions. Springer Nature. September 2020. 1. Agan T. Exploring deaf physicians’ and physician trainees’ experiences with designated interpreters. 2018. Retrieved from Sophia, the St. Catherine University repository website: https:// sophia.stkate.edu/maisce/5. 2. Argenyi v. Creighton University, 703 F. 3d 441 (8th Cir. 2013). 3. Argenyi M.  Technical standards and deaf and hard of hearing medical school applicants and students: interrogating sensory capacity and practice capacity. AMA J Ethics. 2016;18(10):1050–9. https://doi.org/10.1001/journalofethics.2016.18.10.sect1-1610. 4. Argenyi M.  Beyond facilitating communication: the value of designated interpreters. 2019 [online] AM Rounds. Available at: http://academicmedicineblog.org/ beyond-facilitating-communication-the-value-of-designated-interpreters/. 5. Association of Medical Professionals with Hearing Loss. Available at: http://www.amphl.org. 6. Booth A. Integrative fusion. 2013 [online]. Designated Interpreters, LLC. Available at: https:// www.designatedinterpreters.com/deaf-professionals/integrative-fusion/. 7. Booth A.  Designated interpreters are different: examining a growing field. 2016 [online]. Available at: https://streetleverage.com/2016/09/ designated-interpreters-different-examining-growing-field/. 8. Coalition on Disability Access in Health Science and Medical Education. Available at: http:// www.hsmcoalition.org. 9. Featherstone v. Pac. Nw. Univ. of Health Scis., No. 1:CV-14-3084-SMJ, at *18 (E.D. Wash. Jul. 22, 2014). 10. Hall WC, Elliott M, Cullen JP. Designated interpreters: a model to promote the diversity and inclusion of deaf professionals in academic medicine. Acad Med. 2019;94(5):697–700. https:// doi.org/10.1097/ACM.0000000000002570. 11. Hauser PC, Finch KL, Hauser AB. Deaf professionals and designated interpreters: a new paradigm. Washington, DC: Gallaudet University Press; 2008. muse.jhu.edu/book/3790 12. Hori J, Meeks LM.  Access in surgery: CART as a method of inclusion for deaf and hard-­ of-­hearing learners. Disabil Compliance High Educ. 2017;23(1):7. https://doi.org/10.1002/ dhe.30331.

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13. Kezar LB, Kirschner KL, Clinchot DM, Laird-Metke E, Zazove P, Curry RH.  Leading practices and future directions for technical standards in medical education. Acad Med. 2019;94(4):520–7. https://doi.org/10.1097/ACM.0000000000002517. 14. Knight M.  Wearable realtime slides. 2014 [online]. Blog.stenoknight.com. Retrieved from: http://blog.stenoknight.com/2014/04/wearable-realtime-slides.html. 15. Laird-Metke E. Disability decisions by committee: an increase in risk and decrease in student well-being. Disabil Compliance High Educ. Wiley Periodicals, Inc. 2016;21(7):8. https://doi. org/10.1002/dhe.30148. 16. McKee MM, Smith S, Barnett S, Pearson TA. Commentary: what are the benefits of training deaf and hard-of-hearing doctors? Acad Med. 2013;88(2):158–61. https://doi.org/10.1097/ ACM.0b013e31827c0aef. 17. McKee M, Case B, Fausone M, Zazove P, Ouellette A, Fetters MD. Medical schools’ willingness to accommodate medical students with sensory and physical disabilities: ethical foundations of a functional challenge to “organic” technical standards. AMA J Ethics. 2016;18(10):993–1002. 18. Meeks LM, Engelman A, Booth A, Argenyi M. Deaf and hard-of-hearing learners in emergency medicine. West J Emerg Med. 2018; https://doi.org/10.5811/westjem.2018.8.38550. 19. Meeks LM, Jain N.  The guide to assisting students with disabilities. New  York: Springer Publishing; 2016. 20. Meeks LM, Jain N.  Accessibility, inclusion, and action in medical education: lived experiences of learners and physicians with disabilities. Washington, DC: Association of American Medical Colleges; 2018. 21. Meeks LM, Laird-Metke E, Rollins M, Ghandi S, Stechert M, Jain N. Practice brief: accommodating deaf and hard of hearing students in operating room environments—a case study. J Postsecondary Educ Disabil. 2015;28(3):383–8. 22. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013; https://doi.org/10.1097/ACM.0b013e31827c0d60. 23. Moreland C, Agan T. Educating interpreters as medical specialists with deaf health professionals. In: In our hands: Educating healthcare interpreters. Washington, DC: Gallaudet University Press; 2012. p. 147–63. 24. Nicodemus B, Swabey L, Moreland C. Conveying medication prescriptions in American Sign Language: use of emphasis in translations by interpreters and deaf physicians. Transl Interpret. 2014;6(1):1–22. 25. Registry of Interpreters for the Deaf. Medical interpreting roundtable. Winter views. 2019 [online]. Available at: https://rid.org/medical-interpreting-roundtable. 26. Swabey L, Agan T, Moreland C, Olson A. Understanding the work of designated healthcare interpreters. Int J Interpret Educ. 2016;8(1):40–56. 27. Weiner S.  Paving the way for physicians with disabilities. 2019. American Association of Medical Colleges. Available at: https://news.aamc.org/diversity/article/ paving-way-med-students-physicians-disabilities/. 28. Vincent M, Edwards P.  Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev. 2016;4:CD002929. https://doi. org/10.1002/14651858.CD002929.pub3. 29. Zazove P, Case B, Moreland C, Plegue MA, Hoekstra A, Ouellette A, … Fetters MD. U.S. medical schools’ compliance with the Americans with disabilities act. Acad Med. 2016;91(7):979–86. https://doi.org/10.1097/ACM.0000000000001087.

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The Student with a Psychological Disability: Rhonda Rapp, a Fourth-Year Medical Student with Depression and PTSD Lisa M. Meeks, Hilit F. Mechaber, Samantha Schroth, Rahael Gupta, and Joseph F. Murray

Case History Rhonda Rapp is a force of nature and was on the fast track to stardom when entering medical school. She scored in the 99th% on the MCAT and was a yoga instructor for teens with physical disabilities before matriculating to medical school. She entered medical school as a Chancellor’s Scholar, which covered her entire tuition. When Rhonda was 12, her mother passed away after a prolonged battle with breast cancer. Her mother’s cancer diagnosis was the critical event that prompted Rhonda’s interest in medicine. An instant favorite among her peers, Rhonda started a weekly potluck study group and outings each weekend, often organizing long hikes and yoga on the beach. She was lucky enough to secure a room in a beautiful old Victorian row house with three second-year students. The house became a weekend hang out with L. M. Meeks (*) Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA e-mail: [email protected] H. F. Mechaber University of Miami Miller School of Medicine, Miami, FL, USA e-mail: [email protected] S. Schroth Northwestern University Feinberg School of Medicine, Chicago, IL, USA e-mail: [email protected] R. Gupta UCLA Resnick Neuropsychiatric Institute, Los Angeles, CA, USA e-mail: [email protected] J. F. Murray Weil Cornell Medical College, New York, NY, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_4

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impromptu study sessions and cooking lessons occurring simultaneously. Rhonda felt complete with her med school “family” and was thriving. She easily absorbed the academic content in her first 2 years of medical school and excelled in her clinical rotations, “honoring” in five out of her six clerkships. Rhonda was required to do night float during her 6-week subinternship in medicine. One evening while walking from the parking garage to the hospital, she was sexually assaulted. Rhonda did not report the assault. Her performance began to deteriorate and she found it difficult to focus. At times, Rhonda broke down crying on the wards and had to excuse herself for 15–20 min before she was emotionally ready to return to the team. Rhonda began therapy with a specialist whom she was able to seek out and connect with confidentially through the medical school counseling center. The counselor encouraged her to report the assault through the Title IX office, but Rhonda refused and did not want to pursue anything further. She was diagnosed with PTSD and depression, and she continued to experience anticipatory anxiety before and at the end of each shift. Unfortunately, the competing demands of the sub-I, preparation for Step 2, and applications to residency kept her from continuing her care. Faculty note that while Rhonda has a good command of clinical knowledge, she displays emotional lability and seems distant. She is having trouble connecting with the team and her patients, is inefficient on the wards, and is not performing at the level of an intern. They have expressed their concern over her mental state. Rhonda is referred to the Dean of Students as she is at risk of failing the sub-I due to deficits in communication and concerns regarding professionalism. In meeting with the Dean, and fully aware of her performance concerns, she discloses her history of the assault and her diagnoses of PTSD and depression. The Dean of Students brings concerns about Rhonda to the student affairs team (including a psychologist, psychiatrist, and disability specialist who work directly with students but were not Rhonda’s treating clinicians) and asks for any suggestions about how to support her.

Perspectives Barriers from the Perspective of the Student Stigma and bias: concerns about stigma and how I will be perceived if I take a LOA for mental health. Concern that teams will not want me on their rotations and I won’t be able to rotate on any clinical service again (or a different service or in a different hospital). Time: the time it takes to manage my anxiety and distractibility in this clerkship and hospital, finding time for mental health appointments and other follow-up medical or legal appointments. The unknown: not knowing that accommodations are available. The rules: policy – leave of absence and concerns about financial impact, educational consequences, housing, and the implications for access to care if I take a leave of absence. Being unaware of school policies for requesting accommodations. Emotions: feeling overwhelmed with life and the prospects of residency. Reporting/licensing implications: I may have to report this on my residency application and disclose issues about my mental health or why I needed a leave of absence. This will negatively affect/impact my future applications for a medical license.

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How to communicate: communicating with clerkship directors and then team members who “need to know” why I’m leaving for appointments and/or my approved accommodations or circumstances. Privacy: how will this be navigated without compromising my privacy in a very subjective environment.

Barriers from the Perspective of the Medical School Student displays emotional dysregulation on wards that is disruptive to the educational environment and to patient care. Student is not connecting with the team or her patients. Student is inefficient on the wards, not completing charts or following up with patients in a timely manner, and is demonstrating unprofessional behavior. Student reports difficulty concentrating, and her clinical knowledge is not at the level of an intern or is not being displayed. School believes she needs to take a leave of absence in order to seek help and have time to focus on her well-being prior to returning to the clinical environment.

 arriers from the Perspective of the Disability Resource B Professional (DRP) Student not knowing about disability office options – how can we improve sharing of vital information about disability disclosure and request for accommodations? Referrals from wellness group and dean’s office. Should we do some training on accommodations for psychological disabilities? What, if any, policies or requirements will need to be amended in order to accommodate the student? Will the student require accommodations in GME, and how can we begin the process of identifying this need early?

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

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Points of Discussion What Do We Know? Rhonda is a second-year student in your program. Rhonda was dx with PTSD, anxiety, and depression following a sexual assault. Her performance is deteriorating and is finding it difficult to fulfill her clinical responsibilities; at times, she breaks down crying on the wards and has to excuse herself for 15–20 min before she is able to return. Preceptors note that Rhonda is inefficient on the wards, displays emotional lability, and when not crying seems “out of it.” Rhonda is referred to the Dean of Students as she is at risk of failing the current rotation, and her faculty are worried about her mental state. In a meeting with the team, the dean brings up Rhonda’s case and asks for any ideas about how to support this student.

What Do We Need to Know? The leave of absence policy and procedure (What criteria need to be met to warrant a leave? What steps must a student complete or what needs to be submitted to initiate a leave? What resources are or are not available during a leave (e.g., psychology, therapy, psychiatry, etc.)? What criteria must a student meet to be eligible to return to school?) How the student might be impacted by the withdrawal of program-based services like counseling? Are there any options for continued support? What do the technical standards say about behavior, communication, or professionalism and how might that impact this student? What are the competencies for the sub-I clerkships? How can we work with other offices to offer wraparound support to this student? Is protected time (as an accommodation) reasonable during a sub-I?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? Clerkship director Attending on the sub-I Dean for clinical curriculum

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Wellness team Title IX coordinator Disability support person Dean of Students/Student Affairs Financial aid administrator Registrar Counseling Center Student Health Center Peer support group

Discussion Questions 1. In assessing Rhonda’s case, would disability and disability services come up as a potential resource for the student at your institution? Why or why not? (a) Do people think about mental health diagnoses as a disability? (b) Is the counseling center or wellness team integrated with disability services? (c) Are counseling and disability viewed as a team, and do they cross-refer on your campus? (d) Is there cross-reference to each of the services on the respective websites and from the student affairs/services website? (e) Are key administrators in all facets/branches of medical education aware that accommodations are available and reasonable for students with psychological disabilities? 2. What is your school/institution’s process for a leave of absence and for reentry when a student needs time away to address a mental health concern? Guidance from the book, Chapter 5: Leave of absence policies should not be restrictive nor serve as a disincentive to taking a leave. Therefore, schools should only require a physician signature and attestation that a leave is necessary for the student’s health. Similarly, return to school should only require the physician attestation that a student is ready to return. Any mention of being able to meet technical standards should include the statement “with or without accommodations” and should link to the designated institutional disability services office (see UF College of Medicine early resolution agreement with OCR # 04-15-2415). If there is a requirement for fitness for duty that occurs for return from leave of absence, then that same fitness for duty screening should be required of all students that took any type of medical leave  – not just for those taking a leave related to mental health.

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If a fitness for duty is required, it should be completed by the student’s physician, not a physician in the medical school. No person on the dean’s team, nor who has an evaluative role over the student, should provide a fitness for duty. Similarly, no member of the student’s family should serve as the treating physician. A nonevaluative member of a wellness team who has been treating the student may provide documentation. The provider’s qualifications and specialty should align with the medical need (e.g., psychologist, psychiatrist, internal medicine, social worker, etc.). 3 . What recommendations should be made for this student? 4. How would you approach responding to the clerkship directors’ concerns regarding this student? 5. Are there accommodations that can be made for this student? Who would determine what is a reasonable accommodation? 6. How would those accommodations be implemented? Who would communicate on behalf of the student and with whom on the team or in clerkship? 7. Can anything be done to ensure protected time (as an accommodation) during the sub-I if Rhonda decides to forgo a LOA? If so, how much protected time is reasonable?

Potential Clinical Accommodations Clinical accommodations Before clerkship Consider impact of having male vs. female preceptor Prioritize student request for specific placement site Allow student to preview placement site ahead of time Discuss provision of protected time to attend necessary therapy during clerkship Discuss how to communicate about protected time with clerkship director and with team

During clerkship After clerkship Performing chart review the night before Remediate skills to prepare without notice on transcript Utilize a smart pen to record patient interactions Sleep hygiene – not doing nights (or night floats) Permit student to briefly step away to care for medical needs – usually 1–2 h per week with time for transportation to/ from appointment to be made up at alternative time Regular feedback sessions with student and preceptor

Additional considerations Decompressing frequency of clinical rotations as an alternative to LOA – it is important to assess the impact of this solution on the student’s financial aid or loan repayment. If necessary, move or rearrange schedule to allow student to withdraw from current placement site. Can the student miss a day for significant flare of symptoms? Assess the number of clinical hours a student must complete for the rotation, and determine the number of acceptable absences with makeup.

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Disability Insurance Disability insurance can be a life raft for a student trying to decide if they can afford a leave of absence. In Chapter 5 of this text, the authors discuss the varied importance and attention given to disability insurance. Given the large number of students who acquire a psychological disability across all health science fields (see Chapter 5, Table 5.1), and the financial consequences that accompany psychological disability and leave of absence, schools should work to include disability insurance as part of the overall student fees. For medical schools, the LCME standards for accreditation of medical schools require that a school must ensure that disability insurance is available to each medical student. 12.6 Student Health and Disability Insurance

A medical school ensures that health insurance and disability insurance are available to each medical student and that health insurance is also available to each medical student’s dependents. Students with mental health concerns often chose to stay in a program, rather than take time away, given the financial burden of taking a leave of absence. Given the low cost for disability insurance, it is a reasonable investment to make to avoid having to choose between mental health and financial well-being.

 ould Having Student Disability Insurance Have Helped W Rhonda Rapp? The LCME requires that medical schools offer medical students the opportunity to purchase disability insurance. Rhonda might have faced this choice prior to starting to medical school: should I sign up for it?

References and Resources One could imagine Rhonda, when faced with all of the financial decisions involved in starting school, e.g., signing large student loan contracts, enrolling in health insurance, paying computer fees, buying textbooks, securing a lease for housing, etc., might have looked at voluntary disability insurance as one of the items she could probably skip. After all, this “force of nature…on the

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fast track to stardom” might not see herself as someone who would ever need disability insurance. With the cost of medical education skyrocketing, and with the desire to lower one’s eventual debt burden, it might seem reasonable to skip this optional offering.

However, it is in this high-cost, high-stakes environment of medical education that disability insurance gives students some breathing room to address medical conditions that might require time off. It is a lifeline to a struggling student.

Think about what happens if someone has to take time off and go on a leave of absence. Some schools do not allow students on a leave of absence to remain in campus housing or have access to student health services. Even if those students were able to remain housed and have student health access, students on a leave cannot obtain federal loans during times they are not enrolled as an active student to pay for their housing or student health fees. To add insult to injury, some loans require students to begin repayment, and the clock starts ticking when a leave begins. Taking a leave of absence is expensive, and without disability insurance, students who might be struggling medically and emotionally wind up struggling financially as well.

Rather than relying on students’ opting into purchasing disability insurance, schools should consider purchasing student disability for all. Schools who have policies in place should review those policies to identify if mental healthcare needs would qualify for coverage as part of a medical leave of absence.

Schools who proactively purchase disability insurance for their students send a clear message: if you need to take some time off, we want to afford you the ability to get the care and support that you need without unnecessary financial stress. What a powerful statement to a future physician!

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Chapters 5 and 10 from the book Disability as diversity: a guidebook for inclusion in medicine, nursing, and the health professions. Springer Nature. 1. Gupta R.  I solemnly share. JAMA. 2018;319(6):549–50. https://doi.org/10.1001/ jama.2017.22135. 2. Meeks LM, Herzer K, Jain NR. Removing barriers and facilitating access: increasing the number of physicians with disabilities. Acad Med. 2018;93(4):540–3. 3. Annonymous. In my experience. How educators can support a medical student with mental illness. Acad Med. 2019; https://doi.org/10.1097/ACM.0000000000002953. 4. National Academy of Medicine. Clinician resilience and well-being—National Academy of Medicine. 2018 [online]. Available at: https://nam.edu/initiatives/clinician-resilience-andwell-being/. Accessed 28 Oct 2018. 5. Meeks L, Jain NR. Accessibility, inclusion, and action in medical education: lived experiences of learners and physicians with disabilities. Washington, DC: Association of American Medical Colleges; 2018. 6. Drolet BC, Rodgers S.  A comprehensive medical student wellness program—design and implementation at Vanderbilt School of Medicine. Acad Med. 2010;85:103–10. 7. Meeks LM, Ramsey J, Lyons M, Spencer AL, Lee WW. Wellness and work: mixed messages in residency training. J Gen Intern Med. 2019 Jul;34(7):1352–5. 8. Liaison Committee on Medical Education (LCME). Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. Washington, DC/Chicago: LCME; 2016. Effective July 1, 2017. http://lcme.org/publications. Accessed 23 Oct 2019. 9. Meeks LM, Murray JF. Mental health and medical education. In: Medical student well-being. Cham: Springer; 2019. p. 17–58.

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The Student with a Chronic Health Condition: Hillary Hampton, a Second-­Year Medical Student with Crohn’s Disease Nichole L. Taylor and Charlotte H. O’Connor

History Hillary is a second-year medical student, with a history of excelling athletically and academically. In her first year of medical school, Hillary was surprised by the amount of time she had to devote to studying. She knew that it would be demanding, but the reality was far beyond her expectations. She felt unable to balance academics with self-­ care and soon gave up running and regular workouts. Meal preparation also went by the wayside, and Hillary found herself frequently grabbing takeout. She began to experience abdominal pain and occasional diarrhea but passed it off as the product of stress and less-than-optimal nutrition. She was quite certain that she would adjust and soon return to her healthier habits. On the contrary, the stress and symptoms increased. Hillary was experiencing around ten bouts of diarrhea per day. She noticed that her clothes were getting looser and, upon weighing herself, discovered that she’d lost 15 pounds in the past 3  months. In addition, she was experiencing back stiffness and joint pain in her knees, elbows, and hands, which she treated with multiple daily doses of Motrin. When she returned home for Thanksgiving break, Hillary’s mother was shocked by her daughter’s gaunt appearance and insisted she visit their family physician. After a full workup, the doctor diagnosed Hillary with Crohn’s disease.

N. L. Taylor (*) Wake Forest School of Medicine, Winston-Salem, NC, USA e-mail: [email protected] C. H. O’Connor Office of Medical Student Education, University of Michigan Medical School, Ann Arbor, MI, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_5

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Hillary returned to medical school committed to a new regimen of self-care. She shared the news of her diagnosis with her counselor, Jack Richards, and explained her commitment to personal wellness. She tried to eat better, and when she experienced stiffness and pain, she took Tylenol with good results. As she settled into her new routine, she felt more balance in her life. She gained back a bit of the weight, and her pain and stiffness subsided somewhat. The diarrhea was occurring less frequently, and soon Hillary was beginning to feel more like her former self. Fast forward to her M2 year and her first clerkship, internal medicine, Hillary purposefully scheduled this clerkship first, as it had a reputation of being demanding and she felt prepared for a challenge after her 1-month summer break. However, the new schedule, long days, and challenges on the wards resulted in a return to the stressful feelings of her first year of medical school. Hillary had little time to exercise and eat well and was often sleep deprived. Soon the bouts of diarrhea were occurring more frequently, which was an additional source of stress. Hillary had to make frequent quick exits to the nearest restroom and always carried a tote bag containing a change of clothes, “just in case.” When Hillary shared details of her present situation with Jack, he suggested she register as a student with a disability to receive accommodations. Hillary resisted. She worried that the word “disability” may negatively impact opportunities to get into a top residency program. Furthermore, she did not want to be treated differently, and due to the nature of Crohn’s, she was embarrassed to share her diagnosis. In a clinical competency committee meeting at which Jack was present, a faculty member raised concern that Hillary “disappears” from the wards often and has the odd habit of carrying a tote bag with her at all times. Recently she had arrived late to clinic and didn’t seem to have the focus and energy she had displayed earlier in the rotation. The group discussed whether this perceived strange behavior warranted the filing of a professionalism concern note. After some spirited discussion, the committee agreed to continue to observe Hillary and to return to the issue of professionalism at a future meeting. Jack sat silently, deeply concerned about how faculty was perceiving Hillary. The next day, Jack met privately with Hillary to discuss again the benefits of registering as a student with a disability. He explained that by not disclosing, she is at risk of having her action being perceived as professionalism lapses and documented in her file, which would be a definite blemish on an otherwise impeccable medical school record. Reluctantly, Hillary agrees to register with the university’s Office of Disability Services.

Perspectives Barriers from the Perspective of the Student Pressure to be on time and present even when she is not feeling well. No ability to establish a reliable and predictable personal wellness routine during her demanding clerkship.

5  The Student with a Chronic Health Condition: Hillary Hampton, a Second-Year… Pain and feeling unwell affect her ability to perform at the level she is capable. Disclosing her disability may impact her future opportunities. She is afraid this will be disclosed when she applies to residency. Being treated differently and the impression she is receiving favoritism. Embarrassment by the nature of her disease.

Barriers from the Perspective of the Medical School Carrying a tote bag, which seems to be an “odd habit.” Professionalism concerns: arriving late and not being present. She seems disengaged or disinterested. Unwillingness to ask for help.

 arriers from the Perspective of the Disability B Resource Professional ODS is unable to help students who do not register. False perception among students that disability information is not private. Unfamiliarity with the clinical space. What types of accommodations are feasible?

Deconstructing the Barriers and Access Issues Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Additional Questions What, if any, accommodations can be made for this student? Will accommodations vary from rotation to rotation? What are some of the barriers that impacted the student feeling comfortable disclosing? Are there specific barriers you can think of at your home institution? In the future, Hillary decides to pursue internal medicine with a Fellowship in Gastroenterology. How might her experience with Crohn’s disease impact her future profession and interactions with patients?

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Points of Discussion What Do We Know? Hillary feels unable to balance academics and self-care. Student is diagnosed with Crohn’s disease and experiences diarrhea, joint stiffness and pain, and fatigue [1]. Bouts of diarrhea recur in clinical year; when on IM clerkship, she makes frequent exits to restroom carries a tote bag with a change of clothes, “just in case.” Student rejects counselor advice to register with ODS and fears that “disability” may negatively impact future opportunities. Faculty mistakes students’ fatigue and absences to be a professionalism concern and shares this at a CCC meeting. Counselor meets privately with student to explain that nondisclosure of her disability may result in the filing of a professionalism concern. Student agrees to register with the university’s Office of Disability Services.

What Do We Need to Know? Can we obtain a locker convenient for her clerkship rotations where she can keep a change of clothes and other hygiene items? Can the medical school offer accommodations, such as breaks during long procedures, bathroom breaks, time off for healthcare appointments, and a different testing area, as leaving may be disruptive. Can we adjust her schedule to make sure that she does not have back-to-back difficult rotations? Can we decrease her travel time to offsite locations? Is her condition currently stable? If it changes over the course of time, we may need to provide information on leave of absence policies and procedures. What is the process for the students to obtain a leave of absence? How can we work with other offices to provide the necessary resources to support the student? How can we help/coach her with disclosure, if she feels necessary to explain, while on her rotations?

Where Can We Find the Information Needed? Potential campus partner Counselor

Questions to be answered Have you met this student? Have you given her referrals to campus resources? Has she asked for help? Is she open to assistance? Internal Medicine Have you worked with students with disabilities in the past? How are Clerkship Director accommodation needs communicated to attending physicians and others who are involved? Who can arrange for a locker for this student? Who is the clinical education contact person moving forward – clerkship coordinator

5  The Student with a Chronic Health Condition: Hillary Hampton, a Second-Year… Potential campus partner Attending on the internal medicine rotation Wellness team Disability resource professional Assistant Dean of Students Scheduler

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Questions to be answered Are you familiar with accommodations and student privacy? What resources are available to medical students with chronic illnesses? What reasonable accommodations will this student require on her internal medicine clerkship? Other clerkships? How will accommodations be communicated? Does the student know the benefits of receiving accommodations? Potential risks if she does not receive accommodations? How is information disseminated to faculty about referring students to resources when something seems amiss? Does training exist? Can this student be assigned to services that do not require (1) a long commute and (2) overnight shifts?

Questions 1. What, if any, accommodations can be made for this student? Will accommodations vary from rotation to rotation? 2. Are there specific barriers to inclusion in the clerkship portion for a student with IBS at your institution or in your program? Barriers might include: (a) Difficulty relaying confidential information to individual clerkships to make sure the student receives the appropriate accommodations (b) No disability liaison to facilitate the process of attaining clinical accommodations (c) No clearly defined process to navigate to obtain resources for the student (d) Difficulty getting lockers for learners outside of surgery clerkship (e) Multiple campus locations, some of which require long commutes 3. If in the future Hillary decides to pursue internal medicine with a Fellowship in Gastroenterology, how might her experience with Crohn’s disease impact her future profession and interactions with patients? (a) Her experience provides her a unique insight to better advocate for her patients. (b) Patients can relate better to her if she chooses to disclose her own experiences. (c) Emotional burden of disclosing or not. Potential accommodations Provide frequent breaks, especially for long clinical procedures. Allow time off for treatments and healthcare appointments. Offer different testing area, as leaving may be disruptive. Schedule offsite clinical locations that require shorter travel time. Consider the order of clerkships and the services to which she is assigned. Know that her condition could change over time and accommodations may need to change as well; allow for flexibility.

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Discussion What can we learn from this case? This case illustrates the importance of a student’s timely self-disclosure of a disability [2]. Though they may not wish to identify with the term “disability,” by not receiving accommodations, they may be perceived by their evaluators as being unprofessional [3]. While details of disability and accommodations are not disclosed by the medical school, a professionalism concern appears on a transcript and has the potential to negatively impact future educational and/or career opportunities. Chapter 4 of Diversity as Disability discusses ways in which medical school admission teams may offer a welcoming vision/mission statement that may reduce the stigma surrounding disability and to alleviate students’ fear that they will be seen as less qualified than their nondisabled peer if they disclose and receive accommodations for a disability [ 5]. What is the importance of referral to the Office of Disability Services? Hillary’s case is a classic example of the downward spiral that may result from an unaccommodated disability. More specifically, it demonstrates the negative consequences that may occur when a student does not act upon a referral to seek accommodations [4]. It was fortunate that Hillary’s counselor was aware of the impending professionalism concern and was able to alert her of the importance of following through with the office of disability services. Since the faculty member had a false impression of the reasons behind her demeanor and behavior, the consequences of a professionalism concern likely would have negatively impacted her future opportunities. How can we ensure that student behavior due to disability is better understood? The responsibility to communicate the need for accommodations is shared among three parties: the institution, the faculty, and the student [4]. An institution should provide awareness that disability accommodations are available through its website and through announcements made during medical school orientation. In addition, learners should be made aware of the conditions falling under the term disability. Faculty should receive training on disability and accommodations, as well as ways to engage in a conversation with a student, no matter how difficult, if unacceptable behavior is observed in the classroom or clinic. Faculty training could cover evaluation of behaviors that may be attributable to something other than professionalism and steps to take prior to filing a formal professionalism concern. Students have a responsibility to seek help when they are encountering difficulty and to discuss possible solutions with their counselors, coaches, student affairs deans, or disability resource providers [2]. In this case, Hillary’s counselor suggested that she seek accommodations, but did not present her with the possibility of negative consequences should she ignore his advice.

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How can students with chronic health conditions navigate medical school? An open and honest conversation between the DRP and the student should take place as early as possible. With the DRP, the learner can assess the many benefits and minimal risks of disclosing a disability in medical school prior to making a decision to register for accommodations. Potential accommodations and why they reduce barriers. Chapter 5 of Diversity as Disability offers a wealth of information for students with chronic illnesses in both didactic and clinical settings and details the implementation of specific accommodations [5]. For clinical students with chronic health conditions, nearly all will require time off to attend medical appointments and practice self-care. Depending upon their specific condition, others may need to take breaks during the day and be scheduled on specific services (e.g., no overnights) and any other accommodations that relate specifically to the learning environment and the student’s disability. Chapter 10 of Diversity as Disability provides a detailed discussion of barriers encountered by health science students with chronic health disabilities and identifies factors to consider when determining accommodations such as the order of rotations in a student’s schedule, commute time, planning proactively for possible flares, and the allowance for time off to attend medical appointments and physical, occupational, or other therapy [5]. How might Hillary’s experience inform her patient care in the future? Doctors with disabilities are in a unique position to engage with their patients with disabilities. Though one does not need firsthand experience to be caring and empathic, the lived experience of a physician with a disability could bring an element of understanding of patients not attainable in any other way. Likewise, patients may feel a deeper sense of trust in a physician who shares a similarly lived experience. As a gastroenterologist, Hillary can treat her patients with a deep understanding and, if she wishes to disclose her own disability, may form a relationship of trust with her patients [6, 7].

References 1. Qureshi SR, Abdelaal AM, Janjua ZA, Alasmari HA, Obad AS, Alamodi A, Shareef MA.  Irritable bowel syndrome: a global challenge among medical students. Cureus. 2016;8(8):e721. Published online 2016 Aug 1. https://doi.org/10.7759/cureus.721. 2. Jackson V, Henderson DI, Edwards DW, Raines GM.  Accommodation strategies for health sciences students with disabilities. J Best Pract Health Prof Diversity Educ Res Policy. 2011;4(1):585–94. 3. Hicks PJ, Cox SM, Espy EL. Medical education reviews – dealing with student difficulties in the clinical setting. J Obstet Gynecol [Internet]. 2005;193(6):1915–22. Available from: Clinical opinion. 2005;193(6):1915–22.

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4. Steinert Y.  The “problem” learner: whose problem is it? AMEE Guide No. 76. Med Teach. 2005;35:4. 5. Chapters 4, 5, and 10 from Disability as diversity: a guidebook for inclusion in medicine, nursing and the health professions. Springer Nature. September 2020. 6. Meeks LM, Jain NR. Accommodating chronic health conditions in medical education. Disabil Compliance High Educ. 2018;88(2):224–32. 7. Meeks LM, Jain N.  Accessibility, inclusion, and action in medical education: lived experiences of learners and physicians with disabilities. 2018. Available from: https://store.aamc.org/ accessibility-inclusion-and-action-in-medical-education-lived-experiences-of-learners-andphysicians-with-disabilities.html.

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The Student with Cancer: Marc Fernandez, a Fourth-Year Medical Student with Cancer Nichole L. Taylor, Catherine Moore, and Suzanne Hawks

History Marc Fernandez is a friendly and energetic medical student. Coming from a family of scientists, he always felt pulled to medicine. After witnessing his grandfather’s fight with lung cancer, Marc decided he wanted to become a surgeon. On top of his academic success, he enjoys volunteering at his local free clinic and playing in community soccer games. Since starting medical school, Marc has been actively involved in research and won multiple awards for basic science and clinical research projects. He has worked hard in medical school and feels that his successes and experiences each year support his dreams of becoming a general surgeon. Much to his shock, Marc is diagnosed with colon cancer during the beginning of his fourth year of medical school. He studied cancers during his preclinical years and even saw colon cancer patients during his colorectal surgery rotation as a third year but never imagined he would be a patient. His first thought, after that life-­ changing phone call, was about his future as a physician: can I still graduate on time? Can I still become a physician? He wondered how and if he should disclose his disability in his personal statement? Could he possibly balance the time and focus demanded of his challenging surgical subinternships with the sudden N. L. Taylor (*) Wake Forest School of Medicine, Winston-Salem, NC, USA e-mail: [email protected] C. Moore Department of Obstetrics and Gynecology, George Washington University, Washington, DC, USA e-mail: [email protected] S. Hawks Wake Forest University, Winston-Salem, NC, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_6

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onslaught of new appointments, imaging and testing, and inevitable treatments? On top of that, residency applications were due in a few months, followed by interviews. He has been preparing for this point in medical school since the beginning, and this new cancer diagnosis threatens to disrupt his trajectory or bring his medical training and future prospects to a halt. These are uncharted waters for Marc, and he has no idea how to proceed. Knowing he needed help, he reached out and met with his faculty advisor. They discuss a myriad of options, debating the pros and cons of continuing with his medical training versus taking a year off to focus on his health and returning next year. His advisor is concerned that Marc’s performance on his subinternship rotations could be affected by this new diagnosis and absences for medical appointments and treatments. Marc expresses a concern about when and how to disclose his diagnosis and potential future accommodations to residency programs during the interview process or after he successfully matches at a general surgery program.

Perspectives Barriers from the Perspective of the Student May not be aware of disability resources, since he did not need these until his fourth year of medical school. Doesn’t know if accommodations exist in GME Pressure to continue original plan of completing acting internship rotations (30-day interviews) and applying for residency on time Fear the interviews on the recruitment committees will notice hair loss from chemotherapy which could hurt his chances of matching in general surgery Concern interviewing across the country while receiving chemotherapy will make them more prone to acquired community illnesses (flu, cold, etc.) Cost of healthcare and treatments when living on student loans Less invasive surgery or not as aggressive chemotherapy which may allow Marc to miss less coursework and stay on track Desires privacy Disclosing to the program director and not obtaining accommodations Uncertain how disability is handled when he enters residency as a resident in training and an employee

Barriers from the Perspective of the Medical School Concern about how side effects of chemotherapy will impact performance on clinical rotations and the ability to obtain required letters of recommendation needed to apply for residency Concern for the safety of the student as they may treat patients with infectious diseases and undergoing chemotherapy as an immunosuppressant (decreases the immune system) How to/or should we disclose disability in MSPE and in personal statement? Will this affect his ability to match into general surgery residency? Will Marc receive support and flexibility in residency?

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 arriers from the Perspective of the Disability Resource B Professional (DRP) Concern about lack of flexibility regarding last-minute rotation change Learning and retaining information while dealing with side effects from treatment Are accommodations available for residency and how does the student request these accommodations?

 otential Barriers from the Perspective of the Program Director P (PD) If Marc Discloses What accommodations will we need to put in place and how will this impact schedules? Uncertainty of Federal Family and Medical Leave Act benefits on a new employee Adequacy of financial coverage for short- and long-term disability insurance, if needed Ability of the resident to manage the transition to residency superimposed on a cancer treatment regimen Concern about the boundary between being a supervisor, evaluating the resident’s performance, and providing emotional support appropriately

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know? Marc is a fourth-year medical student and is diagnosed with colon cancer. He is academically doing well and appears to be a competitive candidate and planning to apply for general surgery residency. He is scheduled for a subinternship in a surgical oncology rotation. He needs to get letters of recommendation and good evaluations in a short period of time for his residency application.

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He will have significant absences from his rotations to see doctors, undergo surgery, and begin chemotherapy. With assistance from his faculty advisor and DRP, he is able to obtain a schedule change to a more flexible rotation in the preoperative assessment clinic. Marc is uncertain how to disclose his need for accommodations to his new program director where he will start his residency training.

What Do We Need to Know? Even though the school policy requires a month’s notice for a schedule change, can Marc obtain a more flexible subinternship rotation that will allow him to attend doctor appointments and begin chemotherapy? Does Marc’s medical condition and treatments impact his performance on his fourth-year rotations? Is he still continuing to perform at a high level, like his previous 3 years? What is the impact if Marc applies to residency programs and then has to withdraw his applications? Will this affect his application next year? Does the school have an option for Marc to work in research for a year, allowing him to continue to build his residency application, but have the flexibility to attend appointments and treatments? What are the pros and cons of addressing his disability and need for accommodations in his personal statement? During his interview? After he matches at a specific program?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine the Appropriate Disclosure to Obtain Accommodations and Support for This Student at the New Institution? Potential partner Human Resources

Questions to be answered How does a new employee obtain accommodations during residency? What are the employee assistance programs available to support the resident, if needed? What are the options for a leave of absence during residency (personal leave of absence and/or Federal Family and Medical Leave Act (FMLA))? Is there a disability resource professional to assist with accommodations? Does the resident qualify for short- and long-term disability, if needed? Does the resident have the option to buy into the group long-term disability insurance, which would include preexisting conditions, prior to graduating from residency?

6  The Student with Cancer: Marc Fernandez, a Fourth-Year Medical Student… Potential partner Program Director, General Surgery

Designated Institutional Official (DIO), Graduate Medical Education Office State Medical Board

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Questions to be answered Is there flexibility in the residency rotation schedule to allow the resident to attend chemotherapy treatments and doctors’ appointments? Is there a nonclinical rotation or research experience that would allow flexibility for the resident, if the resident needed some time to recover from adverse reactions to the chemotherapy or needs additional surgery? How should the resident notify the program director if they are sick or need to take a medical leave of absence? What are the policies and procedures for paid time off while on a leave of absence? Does the GME Office offer an additional resource, disability resource professional assistance, when requesting time off or accommodations? Is there a policy for residents that are immunosuppressed and guidance on direct patient care of infectious patients? When applying for state licensure after residency, what is the process and guidance for accounting for medical conditions and any time away from training, if necessary?

Discussion Questions 1. In assessing Marc’s case, would disability and disability services come up as a potential resource for the student at your institution? Why or Why not? 2. Do faculty advisors work collectively with a DRP when a student discloses an issue requiring accommodation? If a student discloses a new diagnosis to a clerkship director or a faculty member, are these individuals aware of the DRP services to bring them into the conversations as a valuable resource? Guidance from the book Chap. 12 Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing, and Health Professionals [1]: As medical students progress through medical school and enter residency, they encounter several transitions. The importance of a team to assist the student with navigating these transitions is imperative. The key members of this transition team are the disability resource professional (DRP), career advisor, and advanced career advisor. • The DRP is the key ally and is knowledgeable in the process of requesting accommodations and the barriers for those with disabilities in various subspecialties of medicine and maintains an understanding of the differences in the laws that govern inclusion between the educational and employment settings. • Career advisors understand the wide selection of medical specialties that medical students will be considering when applying to residency. For the medical student still deciding between medical specialties, a career advisor can help the student assess “the fit” for a myriad of specialties. In addition, career advisors assist the student with building their residency application and provide guidance in selecting extracurricular activities (research experiences, volunteerism, leadership, teaching, and mentoring extracurricular activities) and target exam scores required by each different specialty.

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• Advanced career/specialty advisors can provide specific information on the specialty that the student has elected to pursue. This advanced career advisor most likely is practicing in the desires residency specialty and can provide additional guidance on preparing a strong application for this specific specialty. Building a relationship with an advanced specialty advisor will provide the student with an in detailed and personal letter of recommendation endorsing the student’s success in the field they will apply to for residency. It is important that students and all faculty (i.e., clerkships directors, dean’s, and evaluators) are aware of the resources available and the role of the DRP. Students can acquire a disability at any point in their medical education/ training, and the student may not be aware of the resources available. Marketing and education to the entire medical school employees are key to ensuring the student is directed to the DRP in their time of need. The DRP can then reach out to advisors and mentors and build an ideal collaborative team for the individual student. This collaborative team provides accommodations and resources and imparts knowledge to the medical student to assist them in transitioning from medical student into residency. A case-specific accommodation and transition plan is essential to decrease anxiety and insuring success for all students with disability as they transition into residency training [1]. As discussed in the AAMC Webinar Disclosure at All Points UME and GME, disclosure of the disability to the appropriate individual in GME allows for preplanning of accommodations prior to the starting employment and training [2]. 3 . What advice do disability services provide to prepare the student for the transition from medical school to graduate medical education (GME), where the student will become a resident in training and an employee? Guidance from the book Chap. 12 Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing, and Health Professionals [1] identifies the multifaceted roles of the program director, Graduate Medical Education Office, human resources, state medical licenses boards, and specialty board as depicted in Table 6.1. Figure 6.1 was initially published in JGME [3] and provides guidance on disclosure and requesting accommodations when a medical student transitions from UME to GME. The medical student with a disability should contact Human Resources, specifically the ADA expert, at the institution where they will begin their residency training and employment. The ADA expert will confidentially discuss the accommodation options with the employee. The ADA expert discusses the accommodation with the program director and either agrees to implement these accommodations or may need to seek outside consultation for potential creative approaches and implementation. It is important that the ADA designee is involved if the barriers need to be readdressed to refine throughout the resident’s training. 4. How could the program director, designated institutional official, and/or human resources improve the culture for the student to feel comfortable disclosing a

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Table 6.1  Roles of human resources, ACGME, GME/DIO, program director, specialty board and State licensing board involved in accommodation requests and implementation [1] Human resources Leave of absence/ FMLA

Short-/ long-term disability

ACGME Sets minimum requirements in specialty experience (i.e., number of procedures, diversity of cases, rotational experience requirements) Provides individual programs with accreditation

Health insurance benefits

Mandates ADA compliance programs to be compliant with the institution’s policy

Institution GME/DIO Oversees compliance of the individual residency programs with the ACGME requirements

Supports program directors and residents in the institution Interfaces with HR regarding LOA, benefits, and disability as needed Recommended to have a policy and procedure for a resident to request and obtain accommodations

State licensing Program director Specialty board board Provides Reviews Supervisor both significant time assesses the residency away from resident’s in-training training to progression license determine if toward residency should and full competency in license be extended the specialty

Reports resident Determines performance to board certification the specialty board Accommodations Completes for exams paperwork for future job competencies based on residency performance Works with human resources to implement the accommodations

disability and/or need of accommodations during several key times throughout the matching process? Chapter 4 of Disability as Diversity [1] describes several opportunities a program and an institution can communicate a welcoming and inclusive environment for diversity and disability. • Policies and procedures related to requesting accommodations should be clearly posted in multiple sites and should be included on relevant websites and in relevant admission materials [1] (see exemplar language Table 6.2) [4]. • A statement from the residency program director in written brochures/informational packets and/or in the residency program introduction on interview day communicated a commitment to diversity and inclusion.

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Trainee contacts designated ADA expert for confidential consult

If trainee decides to move forward in the process, ADA designee reaches out to program director

Documentation goes to ADA designee only and is confidentially stored

ADA designee returns to resident with potential accommodation paln

PD and ADA designee seek outside consultation about potential/creative approaches (literature review, list-serv queries, calls to other programs, association resources)

Program director communicates essential functions of residency program and potential reasonable accommodations or modifications

Program implements approved accommodations in a manner that respects resident privacy

If accommodations do not fully remove barriers, trainee re-engages in process with ADA designee

Fig. 6.1  An exemplary process in accessing accommodation in graduate medical education (GME) [4]

• The GME Office holds new resident orientations prior to residents starting in the clinical environment. Human resources typically provide information during this orientation regarding various benefits available to the new employees. A joint statement by GME and HR regarding accommodation requests, leaves of absences, and disability procedures and policies can introduce the appropriate first contact for the resident with a disability. 5 . What are some additional resources that I can learn more about assisting a student who has recently been diagnosed with a disability or would benefit from being involved with a community involved in disability in the medical health sciences? The Doctor’s with Disability Campaign [5] is a series of podcasts that discuss the lived experience of doctors throughout the United States who live with a disability and discuss how the disability has impacted their career and leaders on the forefront of creating disability policy. The Coalition for Disability Access in Health Sciences and Medical Education [6] is a collaboration of institutions that aim to improve the experience of students with disabilities. There website have articles, webinars, and a listserv that is a helpful resource in removing barriers in the clinical environment in medicine. The Society for Physicians with Disabilities [7] is an organization that provides a supportive community and resources for students and healthcare professionals that are disabled.

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Table 6.2  Examples of exemplar language for GME programs was published in the JGME [4] and demonstrates a culture if inclusion for all learners Statement of commitment to diversity Program information for applicants Program information for matched residents

Program information for current residents

As part of our commitment to diversity, [name of program] seeks to attract and educate trainees who will make the population of healthcare professionals representative of the national population. We are therefore committed to the full and meaningful inclusion of qualified trainees with disabilities [Name of program] welcomes qualified applicants with disabilities who meet the essential functions of the training program, with or without reasonable accommodations. If you are an applicant with a disability who needs accommodations during your interview, please contact [insert appropriate office and contact information for office] [Name of program] aims to create a fully accessible environment for trainees. Trainees with disabilities who require accommodations to meet the essential functions of the residency should contact [insert appropriate office and contact information for office] to begin the process. [Name of program] values disability as a form of diversity in our program and engages in a robust interactive process to determine reasonable workplace accommodations [Name of program] is committed to equal access in our training programs. Trainees with newly acquired or previously undiagnosed disabilities may require accommodations to fully access training and education. We encourage trainees with disabilities to seek necessary accommodations. Trainees can begin this process by contacting [insert appropriate office and contact information for office]. [Name of program] values disability as a form of diversity in our program and engages in a robust interactive process to determine reasonable workplace accommodations

Meeks et al. [3]

6. What are the requirements of GME to provide accommodations once a student matriculates to residency? From Chap. 12 in Disability as Diversity [1], the Accreditation Council for Graduate Medical Education (ACGME) sets the standards for accommodating residents and mandates requirements, one at the institutional level and one at the program level. ACGME Guidance on Disability Institutional Requirements July 2018 IV.H.4. Accommodation for Disabilities: The Sponsoring Institution must have a policy, not necessarily GME-specific, regarding accommodations for disabilities consistent with all applicable laws and regulations. (Core)

Common Program Requirements (Residency) July 2019 I.D.2.e. accommodations for residents with disabilities consistent with the Sponsoring Institution’s policy. (Core)

As a medical student graduates and enters residency, the landscape for accommodations for disability drastically shifts. The mechanisms for disclosing

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disability and requesting accommodations also shift. Residents in training are both employees of the hospital and trainees supervised by the Graduate Medical Education (GME) Office. Unlike in medical school, human resources (HR) for the institution now sets the standards and develops a process to request accommodations for schedules, accessibility needs, leaves of absence, and short-/longterm disability. Considering the unique roles of residents as employees who are still in training, a collaborative team of disability specialists from GME and HR may be needed to assess the reasonable nature of an accommodation request. It is also helpful to be aware that time away from training must be reported to the specific medical specialty board. Each board will assess time away from training in conjunction with the residency program director’s assessment of proficiency, in cases where extended residency training time is required. 7. What are the legal requirements of GME to ensure equal access to the training program? From Chap. 12 in Disability as Diversity [1], the legal status of a medical resident under the ADA is somewhat complicated by the fact that residents are both employees (ADA Title I) and students (ADA Title II or Title III). As with a medical student or an employed physician, a medical resident with a disability is entitled to request and receive reasonable accommodations. Courts will assess all such requests for accommodations in a similar fashion, as required by the ADA.

Summary A team approach is needed to help gather the required information to assist Marc in obtaining accommodations during medical school and to help him obtain information as he transitions from UME to GME. It is critical that all faculty are aware of the resources available to students, especially when a student encounters a new diagnosis and needs accommodations. It was important in our case that Marc’s faculty advisor was aware of the school resources and connected Marc with the disability resource professional (DRP). The DRP will provide guidance and options regarding accommodations and potential leave of absence. The DRP was instrumental in navigating an exception to the school policy regarding rotation changes outside of the normal 4-week advance notice in their policy. Timing of disclosure by a medical student and the need for accommodation can be difficult to navigate. There are several opportunities for disclosure during the residency application and matching process; residency application, personal statement, during the interview or after matching at a specific residency program. The ideal opportunity of disclosure will be highly dependent on when the student is most comfortable disclosing and can be significantly influenced by a residency program’s welcoming language found on their website, during an interview day program overview and post-match communication. It is imperative that a DRP work collectively to provide the student with a disability the guidance to help them continue the

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successful accommodations they have received while in medical school and optimal time of disclosure. A key resource for a medical student with a disability is the Human Resource Office at their matched institution. The Human Resource Office works in collaboration with the residency program directors to facilitate accommodation in the graduate medical education. The DRP can help demystify the process and multiple players (ACGME, DIO, HR, PD) and organizations involved in their obtaining board certification and state licensure that was presented in the Discussion section of this chapter.

References and Resources 1. Chapters 4, 10 and 12 from Disability as diversity: a guidebook for inclusion in medicine, nursing and the health professionals. 2. Giang D, Meeks LM. AAMC Webinar. Disclosure at all points UME and GME. April 7, 2016. https://www.aamc.org/professional-development/affinity-groups/gsa/webinars/disclosure. 3. Meeks LM, Taylor N, Case B, Stergopolous E, Zazove P, Graves L, et al. The unexamined diversity: Disability policies at the 50 largest US training programs. J Grad Med Educ. 2020. In Press. 4. Meeks LM, Jain NR, Moreland C, Taylor N, Brookman J, Fitzsimons M. Realizing and inclusive workforce. J Grad Med Educ. 2019;11(5):498–503. 5. Coalition for Disability Access in Health Science and Medical Education. https://www.hsmcoalition.org/. 6. Society of Physicians with Disabilities. https://www.physicianswithdisabilities.org/. 7. Doctors with Disabilities Campaign. https://podcasts.apple.com/us/podcast/ docswithdisabilities/id1474844514. 8. Meeks LM, Montgomery T, Moorehead G, Laird-Metke E. AAMC Webinar. Helping medical schools assist students with disabilities: an introduction to the coalition for disability access in health science and medical education. April 14, 2015. https://www.aamc.org/ professional-development/affinity-groups/gsa/webinars/assist-students-with-disabilities.

Part II Nursing Student Cases

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The Student with a Learning Disability: Mee Sook Smith, a Nursing Student with a Learning Disability in an Associate Degree Program Leslie Neal-Boylan, Patricia Lussier-Duynstee, and Christine Low

Case History Mee Sook Smith is in the second year of an associate degree in nursing program. She was adopted from Korea at the age of 3 and has typically found academics challenging. She finds she is most challenged by math and science but also has to read something several times before she fully comprehends its meaning. She had no difficulties in elementary school and has always gotten along well with peers and teachers. Mee Sook began to have some academic challenges in junior high school but was able to overcome them with assistance from her teachers. Once in high school, however, the work became more complex and difficult. Teachers and her parents praised her intelligence and motivation. Her parents engaged after-school tutors to work with Mee Sook. Tutors also worked with her to prepare for the SAT exams. Mee Sook earned test scores that were adequate for acceptance into an associate degree in nursing program at her local community college. Her plan is to complete the degree and transition into a baccalaureate program to complete the bachelor’s degree in nursing science. Mee Sook is having difficulty in her nursing classes and has had trouble passing med math. She is in danger of failing several courses. The faculty are beginning to wonder if Mee Sook can succeed in nursing. The nursing program is teetering on the brink of a warning from the state board of nursing because their nursing board exam L. Neal-Boylan (*) Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA P. Lussier-Duynstee MGH Institute of Health Professions, Boston, MA, USA e-mail: [email protected] C. Low Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_7

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scores have been dropping. Faculty are wondering if it would be better for both Mee Sook and the program to advise her to change majors. Mee Sook has only just begun going into clinical after repeating the med math test several times. Faculty are concerned she won’t be able to keep up with the hospital’s fast-paced environment. Mee Sook seeks the help of her advisor. She is anxious to remain in the program and is highly motivated to become a nurse. She asks her advisor how she can get help. After asking some key questions about Mee Sook’s history in school and whether she has had difficulties or challenges in the past, the advisor asks if Mee Sook has ever participated in testing to evaluate her academic challenges. Mee Sook expresses interest in hearing more and asks for clarification. The advisor probes a little deeper and asks if Mee Sook ever met with a counselor about her concerns and, if so, whether there were any suggestions made beyond tutoring. Mee Sook responds that a series of tutors and the support of her parents and teachers helped her get this far and asks “Is there anyone who can help me here at school?” “How do I find a tutor here?” Her advisor explains the services provided by the Office of Disability Services, refers Mee Sook to their website, and provides a pamphlet for review. The advisor indicates that she will be happy to answer any questions Mee Sook might have after she reviews the website and pamphlet.

Perspectives Barriers from the Perspective of Student I really want to be a nurse but what if I am just not smart enough? My advisor says the Office of Disability Services might be able to help me but I don’t have a disability. Why would she think I have a disability? What if I have a disability and my parents, friends, or teachers find out? Will they think differently about me or tell me I cannot become a nurse? Maybe I should just tough it out and see whether I pass my courses. I am excited about taking care of patients in clinical. What if I make a mistake because I can’t read fast enough or do the medication calculations quickly?

Barriers from the Perspective of Nursing Program Mee Sook did not disclose the disability before entering the nursing program. She should never have been admitted to nursing. She won’t be able to succeed. Even if Mee Sook gets accommodations, she might not pass the nursing board exam. We cannot afford to have another failure. Will Mee Sook be able to care for more than one patient at a time or even one patient with complex needs? Other students might resent it if Mee Sook gets special assistance when they don’t. We are unsure how best to support the student. Working with Mee Sook will require extra time from faculty. We are so tightly stretched as it is. Where will we find the time? Let’s face it. Not everyone can be a nurse. The kindest and most ethical thing to do is advise Mee Sook to go into a different profession.

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From the Disability Resource Professional (DRP) Perspective It is unclear if Mee Sook has a disability at this juncture. It would be helpful to do an intake interview to gather some additional information about her past academic performance, adoptive family, and medical and mental health history What is the ethnicity of her adoptive parents? Are there cultural implications/stigma in being identified as disabled? It seems a thorough neuropsych exam might be the key to identifying Mee Sook’s learning profile and would be helpful in specifying her functional limitations that would lead to identifying potential accommodations. Faculty and staff would benefit from additional training on the legislative mandates regarding providing disability accommodations for students and separating concerns related to the school’s concerns about the State Board of Nursing.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know?

Mee Sook is just discovering that she has a learning disability. Mee Sook has not had time to adjust to this diagnosis or figure out how she will perceive herself as a person with a disability. Mee Sook has had no experience or guidance about how to discuss a potential disability in her academic environment or personal life. Mee Sook, although not aware of it, has been compensating for her disability her entire academic life. Mee Sook has demonstrated that she is intelligent, motivated to succeed, and willing to work hard to achieve her goal. Mee Sook has demonstrated that with the help of tutors and a support system, she is able to achieve her goals.

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Mee Sook has a realistic plan of earning the associate degree first and then pursuing the bachelor’s degree. The nursing faculty are concerned about their board exam test scores, and while willing to help Mee Sook, they are reluctant to put their limited time and energy into supporting her.

What Do We Need to Know?  here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations What are Mee Sook’s functional limitations associated with her learning issues? Were other issues identified in the disability service intake? What accommodations will the Office of Disability Services recommend for Mee Sook? Will the recommendations for accommodations be “reasonable” for the faculty to implement? How can the Office of Disability Services work with the nursing faculty to help them understand that they are required by law to provide reasonable accommodations for Mee Sook and they may not discriminate against her or act in ways that might be construed as retribution for seeking accommodations? Are there additional resources to support faculty/school concerns around testing scores of the students? What resources are available at the College to support Mee Sook? What accommodations, if any, will Mee Sook need in her clinical placements? What simulation exercises are used with all students before starting clinicals? Is there a way to break down complex clinical encounters into component parts to support learning for Mee Sook or for all students? Can simulation experiences be used to ensure Mee Sook is safe in the clinical setting before she starts clinical with real patients? Is this even necessary? Could the timeline to graduation be extended to allow for accommodations such as a reduced caseload for the start of clinical rotations or additional simulation time?

and Support for This Student? Dean or Director of the nursing program Nursing faculty Office of Disability Services

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Clinical supervisors in the clinical agencies Required graduation competencies Technical standards of the program Course syllabi Review of assessment format and timing

Discussion Questions 1. Does your nursing program embrace a culture of inclusion beyond stating you support inclusion of people with disabilities? The nursing program should review its technical standards to be sure they are compliant with the ADA. Modeling inclusion practices for students will help nursing students develop a greater understanding of and empathy for people with disabilities. 2. Are your colleagues knowledgeable about the Americans with Disabilities Act (1990) and how it applies to students? Faculty and administrators may inadvertently be discriminating against students with disabilities. Understanding the ADA and the terms in the ADA Amendment Act (2008) will help create and strengthen a culture of inclusion. Within a college or university, the Office of Disability Services specializes in confirming learning disabilities and accommodations 3. Does your program use a holistic admissions process to ensure you do not discriminate against prospective students with disabilities? The nursing faculty should review the admission process to ensure that students are admitted based on their ability to succeed academically and not based on the essential functions of a nursing job. Applicants are not required to disclose any disability. It is important that faculty remember nurses work in a wide variety of settings so that a student with a disability might be able to work as a nurse but not necessarily in every setting. It is important to understand the distinction between the essential functions of an employed nurse and the technical standards required by nursing students. 4. Do your faculty attend annual professional development on topics of inclusion, implicit bias, and microaggression? An annual update and reminder of how we may unintentionally offend others is important for all faculty and administrators. Faculty in-services utilizing the expertise of the DRP can increase understanding of learning disabilities and decrease the stigma for students. Faculty may want to develop their own philosophy or statement that embodies how the program views people based on their abilities rather than disabilities.

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Potential Accommodations for Mee Sook Didactic course Additional testing time Use of a calculator

Lab Use of a calculator Additional time

Distraction-­ reduced test setting

Simulation Additional practice sessions Breaking of assignments into component parts for practice

Clinical Reduced caseload of patients Opportunities to review patient charts in advance to prepare for patient care Use of a smartpen or other device to record patient interactions Regular feedback sessions with preceptor. Feedback in writing

Guidance from Chap. 6 Self-efficacy is important to the ability to perform a task successfully. Proactive student engagement in the learning process provides students with learning disabilities opportunities to maximize their success. Mee Sook is highly motivated. She has demonstrated self-efficacy and proactive engagement. These qualities have helped her get this far. As a self-regulated learner, she is optimistic that she will accomplish her goals. The faculty can either choose to help her or miss the chance to develop a nurse who will face adversity with endurance and optimism. However, Mee Sook is likely to encounter negative attitudes and implicit bias. Faculty may believe in stereotypes that people with learning disabilities are not intelligent. While Mee Sook may have challenges, faculty should view her capabilities on an individual basis. Faced with new challenges in nursing school, Mee Sook’s natural confidence and optimism may transform to a fear of failure and a reluctance to seek help. The nursing program faculty and administrators have an opportunity to make a huge difference in Mee Sook’s life. Their attitude toward her and her ability may signal whether she can continue to go forward in life to achieve important things and contribute to society or she will hide her natural intelligence and seek experiences that don’t require so much effort and hard work. An important role for nurses is to promote resilience and self-care both in students and in patients.

Summary Mee Sook has demonstrated that she can persevere. She is a role model for her peers and faculty. Faculty and administrators must be careful not to “lose” these potential nurses because of bias surrounding disability. While academic and clinical expectations should not be reduced for someone with a disability, there is more than one way to do most things safely. There is also more than one way to learn material and demonstrate competence. Universal Design is discussed throughout the book. This approach is worth consideration, especially when considering students with

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learning disabilities. Faculty should work with the Office of Disability Services to assess and determine the best accommodations for Mee Sook. In the end, the student will be the best judge of what works for them. It is up to faculty whether what Mee Sook needs to be successful is “reasonable” as defined by the law.

References and Resources 1. Ashcroft TJ, Lutfiyya ZM.  Nursing educators’ perspectives of students with disabilities: a grounded theory study. Nurse Educ Today [Internet]. 2013 [cited 2013 Nov];33(11):1316–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Nursing+educators%27+p erspectives+of+students+with+disabilities%3A+A+grounded+theory+study. https://doi. org/10.1016/j.nedt.2013.02.018. 2. Davidson PM, Rushton CH, Dotzenrod J, Godack CA, Baker D, Nolan MN.  Just realistic expectations for persons with disabilities practicing nursing. AMA J Ethics [Internet]. 2016 [cited 2016 Oct 1];18(10):1034–40. Available from: https://journalofethics.ama-assn.org/ article/just-and-realistic-expectations-persons-disabilities-practicing-nursing/2016-10. https:// doi.org/10.1001/journalofethics.2016.18.10.msoc1-1610. 3. Horkey E.  Students with physical disabilities: uncovering the process of accommodation implementation in clinical nursing education through grounded theory. 2017;1–1. (1p) (Article) ISBN: 9780355570168 AN: 130391003. 4. Marks B, McCulloh K.  Success for students and nurses with disabilities. Nurse Educ [Internet]. 2016 [cited 2016 Jan/Feb];41(1):9–12. Available from: https://www.ncbi.nlm.nih. gov/pubmed/26402910. https://doi.org/10.1097/NNE.0000000000000212. 5. Neal-Boylan L, Miller M. Treatment like everyone else: the experience of nurses who had disabilities while in school. Nurse Educ [Internet]. 2017 [date cited 2017 Jul/Aug];42(4):176–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27922900. https://doi.org/10.1097/ NNE.0000000000000348. 6. Neal-Boylan L, Smith D.  Nursing students with physical disabilities: dispelling myths and correcting misconceptions. Nurse Educ [Internet]. 2016 [cited 2016 Jan/Feb];41(1)13–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26218008. https://doi.org/10.1097/ NNE.0000000000000191. 7. Petersen KH, O’Connor C, Ciesielski S, Eidtson W. Realizing academic success within the health sciences learning environment. In: Meeks L, Neal-Boylan L, editors. Disability inclusion: disability as diversity. Switzerland: Springer; 2020. (Chapter 6). 8. Shpigelman CN, Zlotnick C.  Attitudes toward nursing students with disabilities: Promoting social inclusion. J Nurs Educ [Internet]. 2016 [cited 2016 Aug];55(8):441–9. Available from https://www.ncbi.nlm.nih.gov/pubmed/27459430. https://doi. org/10.3928/01484834-20160715-04. 9. Students’ virtual internship helps build network and boost confidence. Learn Disabil Pract [Internet]. 2019 [cited 2019 Mar 25];22(2):7. Available from: https://journals.rcni.com/learning-disability-practice/news/students-virtual-internship-helps-build-network-and-boost-confidence-ldp.22.2.7.s6/abs. https://doi.org/10.7748/Idp.22.27.s6. 10. Symes J.  Nursing students with disabilities in the clinical setting: nursing education leaders’ perceptions of accommodations [dissertation]. Vermillion: University of South Dakota; 2014. 1 p. 11. U.S. Department of Education: students with disabilities preparing for postsecondary education: know your rights and responsibilities. https://www2.ed.gov/about/offices/list/ocr/transition.html.

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The Student with a Learning Disability: Maxwell Mason, a Nursing Student with a Learning Disability in a Baccalaureate Degree Program Patricia Lussier-Duynstee, Charlotte H. O’Connor, and Leslie Neal-Boylan

Case History Maxwell Mason is a 20-year-old, nursing student in the junior year of a baccalaureate program. His father is an emergency medical technician and his mother is a certified nursing assistant. They are extremely proud that their son was accepted into the Bachelor of Science in Nursing program at the State University and will be the first college graduate in their family. Maxwell loves his nursing classes and is popular among his peers. He displays exceptional skills in the simulation lab and is a team player. He frequently assists others who struggle with particular skills. Since the beginning of the semester, Maxwell has studied daily and worked with a tutor. He attended the faculty review session in preparation for his first exam. On exam day, he feels well prepared and confident in his abilities. During the exam, however, he runs out of time and is unable to complete the last ten questions. This results in missing a passing score by five points. The exam failure results in a mandated meeting with his nursing advisor. In that discussion, when asked to share his academic strengths and past challenges, Maxwell discloses his history of a learning disability. He had been diagnosed with a learning disability in reading in the fourth grade. He had an individualized education plan (IEP) and received academic support throughout elementary and junior P. Lussier-Duynstee (*) MGH Institute of Health Professions, Boston, MA, USA e-mail: [email protected] C. H. O’Connor Office of Medical Student Education, University of Michigan Medical School, Ann Arbor, MI, USA L. Neal-Boylan Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_8

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high school. He worked extensively with tutors to develop his reading skills. By high school, Maxwell believed that he had “outgrown” his reading disability and though he still maintained an IEP on file (at his counselor’s insistence), he rarely used the accommodation of extended time that he was qualified to receive. The nursing curriculum covers a large amount of content at a rapid pace. Because Maxwell disclosed that he has a disability, his advisor is able to recommend that Maxwell meet with a disability resource professional (DRP) in the Disability Services Office on campus to discuss accommodations. At first Maxwell resists [1], but after considering the benefits of accommodations, and realizing that his disability or accommodation status would neither appear on his transcript nor be shared with his peers, he agrees to visit the Disability Services Office. After sharing his history and appropriate documentation, Maxwell receives the accommodations of extended time for exams (at the rate of time-and-a-half) and testing in a distraction-­free room. For the next exam, Maxwell studies just as he had for the first one; he feels prepared on exam day. This time, instead of going to class, he reports to the University Testing Center and takes the exam with accommodations. Maxwell finishes the exam with time to spare. He is able to complete all the questions and even has time to review his responses prior to turning in the test. When the grades are posted, Maxwell is proud that his score places him in the upper half of the class. With renewed confidence, Maxwell continues to work hard. As the next exam approaches, Maxwell overhears a conversation among some other students. He hears them complain about a student who was allowed to have extra time on the exam; they view this as an unfair advantage. The conversation upsets Maxwell [2]. He thinks that perhaps running out of time on the first exam was merely a fluke. He thinks that if he were to make a greater effort to be mindful of the time while taking the next exam, he could forgo accommodations. He decides not to use accommodations for the next exam. On exam day, Maxwell reports to the regular classroom where his peers are preparing to take the test. He has studied hard and is feeling ready. Things initially go well. He feels confident and is familiar with the material. But on looking at the clock, he realizes he still has 15 questions to answer with only 8 minutes of time remaining. He puts down his head and gets back to work. The next time Maxwell glances up, he notices that he is the last person in the classroom. He still has ten questions to complete. By this point, Maxwell is feeling anxious and both his confidence and ability to concentrate have waned. He completes only one more question, leaving a total of nine unanswered. Exam results are posted and not surprisingly, Maxwell has failed the exam. When he next meets with his advisor, Maxwell explains that he now understands he needs to use accommodations to accurately demonstrate his abilities. He describes the discomfort he felt overhearing the students’ conversation about his accommodations. Also, a friend asked him why he wasn’t in the classroom on the day of the first test. He confesses to his advisor that he lied to his friend about having “personal business” to attend to on the day of the first test, since that was easier than trying to explain a learning disability. In his experience, most people think that a learning disability implies low intellect; he doesn’t want to be viewed that way.

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Maxwell realized that acceptance of his disability, though difficult, was something he would need to work through if he wanted to become a successful nurse. He agreed to use accommodations from that point forward and requested that his advisor allow him to retake the most recently failed exam with accommodations. The advisor tells Maxwell that since he chose not to use his accommodations, he is not entitled to a retake. Maxwell asks if his advisor will support him in asking the academic review board to make an exception in his case.

Perspectives Barriers from the Perspective of the Student I need additional time to take exams because it takes me longer to read the questions and answers. I worry about how others will see me if they know I have accommodations. I am concerned that having a learning disability will impact my future. Perhaps no one will want to hire me. I don’t understand why I cannot retake the most recent test. I know I am smart but having to use accommodations makes me feel less intelligent than my classmates.

Barriers from the Perspective Nursing Program The student seems reluctant to using the accommodations he is qualified to use – the administration cannot make him use accommodations. In this case, should this student be allowed to retake the exam? Faculty are hesitant to allow Maxwell extended test-taking time because they know other students may consider the extended time an advantage for the student.

From the Disability Resource Professional (DRP) Perspective Accommodations are available only to qualified students with disabilities who register with Office of Disability Services. Disability is misunderstood. Accommodations level the playing field for students; they do not offer an advantage. Students should be aware that if they waive using accommodations, they are not entitled to an exam retake with accommodations.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

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Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know? Maxwell has had to come to the realization that he requires accommodations. Accommodations are not retroactive so Maxwell cannot be permitted to retake the last exam. The faculty advisor seems knowledgeable about how to assist and advise the student but the rest of the faculty may need training. Maxwell is clearly intelligent and capable of succeeding in nursing school.

What Do We Need to Know? Does Maxwell have any other learning disability besides reading? Will Maxwell need clinical accommodations? Could the timeline to graduation be extended to allow for accommodations such as a reduced caseload for the start of clinical rotations? What other resources are available to assist Maxwell? Are there other considerations beyond his disability that would help Maxwell succeed as a first-generation college student?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? University Office of Disability Services Professional organizations such as the Association for Higher Education and Disability (AHEAD) or the Coalition for Disability Access in Health Science and Medical Education Webinars, workshops, and/or conferences by AHEAD or the Coalition which may be offered to faculty and staff The library – resources about disability and the law Nursing faculty Technical standards of the program

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Discussion Questions 1. How can your program avoid stigma for students who require testing accommodations? The nursing program might consider implementing the principles of Universal Design by allowing all students additional time on exams. For example, instead of allowing 1 minute per question, should everyone be allowed 2 minutes per question? To reduce stigma surrounding disabilities, incorporate teaching about disabilities (including learning disabilities) into the nursing curriculum. This knowledge will allow nurses to better understand and treat patients with disabilities. 2. Are your program’s technical standards compliant with the Americans with Disabilities Act? The technical standards should include what is required to be successful academically in nursing school. They should not include essential functions required for a nurse who is working in a hospital or other setting. Skills requirements should stipulate what must be accomplished, not how it should be accomplished, as long as how it is accomplished is safe. 3. With whom can the faculty share information about the student’s need for accommodations? With the exception of the disability resource provider, details of the student’s disability are not to be disclosed or discussed among faculty members. (Though not required to do so, the student may disclose at his discretion.) Faculty should only share the student’s accommodation information with those with a “legitimate need to know,” such as any person who is carrying out the accommodation (e.g., the person administering the exam in the University Testing Center). 4. What can your nursing program do to ensure fair treatment of students with disabilities and compliance with the ADA? The educational program leadership should provide educational programs/ workshops to help nursing faculty better understand learning disabilities, dispel myths about disability, and reduce stigma. This might include changing the conversation from the focus on “disability” to a focus on “accommodations.” This might diminish the likelihood of labeling students who need accommodations, therefore reducing their sense of diminished worth [3]. Changing the conversation can include explaining that the student receives an accommodation of extra time “per question” rather than extra time “as compared to other students.” The comparison to other students is likely to increase stigma. 5. What additional guidance would be helpful to Maxwell? Be sure that he understands that he can also use accommodations in any clinical setting that may require reading/writing assessments and that he is aware of the process to apply for accommodations for future board exams.

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Potential Accommodations for Maxwell Didactic course Extended time for test-taking Work with an academic coach to maximize learning, reading strategies, and pacing of exams Reduce distractions

Lab Use of a calculator Additional time

Clinical Reduced patient caseload Opportunities to review patient charts in advance to prepare for patient care Regular feedback sessions with preceptor. Feedback in writing

Simulation Additional practice sessions Breaking down assignments into component parts for practice

Maxwell should check in with the DRP at the beginning of each semester to secure appropriate accommodations, based on the types of assessments that will take place in each class. The DRP should contact specific faculty to determine if timed reading/writing is involved and discuss reasonable accommodations

Guidance from Chap. 7 [4] Chapter 7 describes how health sciences programs can increase accessibility through inclusive instruction and design. Systems that ease the student’s access to accommodation services are key. Faculty awareness, confidentiality, and seamless provision of services, such as test-taking environments, can minimize the stress on both students and faculty. Stigma associated with disabilities and academic accommodations is real and impacts the student learner. Reducing the stigma of accommodations can be approached at the organizational level through inclusive Universal Design methods, thus assuring that all students have access to quality learning through intentional accessibility.

Summary Maxwell Mason has traveled a long road to understand his learning needs. Along the way, he recognized his reticence to use testing accommodations because of perceived stigma associated with doing things differently. It is essential to keep the goal of successful program completion in sight at both the individual and organizational levels. The student should request accommodations every semester and use them consistently to avoid lapses, as accommodations are not retroactive. The school of nursing should conduct annual training for faculty about the requirements of the Americans with Disabilities Act and Universal Design.

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References and Resources 1. Marks B.  Cultural competence revisited: nursing students with disabilities. J Nurs Educ. 2007;46(2):70–4. Research Support, U.S.  Gov’t, Non-P.H.S, United States: SLACK INCORPORATED. 2. Lyman M, Beecher M, Griner D, Brooks M, Call J, Jackson A.  What keeps students with disabilities from using accommodations in postsecondary education? A qualitative review. J Postsecondary Educ Disabil. 2016;29(2):123–40. 3. Nelson R. Nurses with disabilities: fear of discrimination still exists, but laws and technology create inroads. AJN Am J Nurs. 2005;105(6):25–6. 4. Petersen KH. Increasing accessibility through curricular design. In: Meeks L, Neal-Boylan L, editors. Disability inclusion: disability as diversity. Switzerland, AG. Springer International; 2020. (Chapter 7).

Suggested Readings Bourke AB, Strehorn KC, Silver P. Faculty members’ provision of instructional accommodations to students with LD. J Learn Disabil. 2000;33(1):26–32. Dupler AE, Alice E, Allen C, Maheady DC, Fleming SE, Allen M.  Leveling the playing field for nursing students with disabilities: implications of the amendments to the Americans with Disabilities Act. J Nurs Educ. 2012;51(3):140–4. Journal Article, United States: SLACK INCORPORATED. Murray C, Flannery BK, Wren C. University staff members’ attitudes and knowledge about learning disabilities and disability support services. J Postsecondary Educ Disabil. 2008;21:73–90. Plank T. Ain’t no mountain high enough: paths for success for nurses with learning disabilities. In: Maheady DC, editor. The exceptional nurse: tales from the trenches of truly resilient nurses working with disabilities. Donna Carol McCready c2014. p. 44–56. Vogel S, Leyser Y, Wyland S, Brulle A. Students with learning disabilities in higher education: faculty attitude and practices. Learn Disabil Res Pract. 1999;14:173–86.

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The Student with a Physical Disability: Sam Stone, a Nursing Student with a Missing Limb Leslie Neal-Boylan, Patricia Lussier-Duynstee, and Jan Serrantino-Cox

Case History Sam is accepted into a state university baccalaureate nursing program based on the established criteria for admission. Upon matriculation, Sam achieves and maintains the required GPA in the first 2 years to support his progression in the advanced portion of the program, which includes clinical nursing courses. Sam was born without a right forearm but does not disclose the disability in the first 2 years. Throughout Sam’s education, the lack of a forearm has not interfered with learning, self-care, or activities of daily living. Sam is quite skilled in navigating daily activities including driving, yoga, and spinning class. Sam navigates new situations quickly and finds interesting and unique ways of completing tasks in novel situations. While unfamiliar with the full extent of the physical skills required in nursing, Sam is confident that the barriers can be easily mitigated using existing compensatory skills and creative approaches to procedures. During the first 2 years of college, Sam is in the general education portion of the program, so the nursing faculty and administration are unaware the student is missing his right forearm. Upon learning this, the nursing program becomes concerned that this disability could impact Sam’s ability to complete competencies in nursing. The faculty initially have concerns and questions when they observe that Sam has a disability. Questions that arise include “why didn’t the student tell us on application about the disability?” “How can he be successful in our program?” “Can or should L. Neal-Boylan (*) Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA P. Lussier-Duynstee MGH Institute of Health Professions, Boston, MA, USA J. Serrantino-Cox Coalition for Disability Access in Health Science Education, Rancho Santa Margarita, CA, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_9

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he be a nurse?” The student explains to his advisor that given his lifelong experience without a forearm, rather than having lost it later in life through illness or trauma, this is his norm and doesn’t consider this a disability since activities of daily living are easily navigated. Sam’s elbow joint allows for some flexibility at the end of his arm, and while a prosthesis is available, Sam rarely wears it because it is mostly cosmetic rather than functional. Focusing on clinical competencies, the nursing faculty wonder whether the student will be able to physically perform the role of an RN and directly ask the student, “Can you be a nurse if you cannot perform some of the routine skills?” The faculty are not convinced that the physical skills, like taking a blood pressure, drawing up medications, administering medications, and dressing changes, can be accommodated. The student is referred to the Office of Disability Services to formally apply for accommodations.

Perspectives Barriers from the Perspective of Student I’m concerned about being treated differently from everyone else. I’m surprised that the nursing program is doubtful of what I can do and accomplish. I’m anxious about going into the simulation lab and finding out the skills I will need to perform. I know some tasks need to be completed quickly and there are high pressure situations. I know some tasks require two hands. How will I be able to manage them?

Barriers from the Perspective of Nursing Program Sam did not disclose the disability before entering the nursing program. This can be a barrier to nursing faculty embracing the situation and positively working toward student success. The faculty are challenged to consider what the essential skills are for a registered nurse providing direct patient care. The faculty are concerned about what the student cannot do in the usual way and whether it will take Sam longer to safely complete activities and perform skills. The faculty wonder if Sam will need specialized equipment and/or the assistance of a teaching assistant. The faculty have doubts that Sam can provide or demonstrate safe patient care. The faculty are unsure how best to support the student. Faculty have concerns about finding suitable and willing clinical placements to allow Sam to practice. Faculty are concerned about how to assess skills that are typically performed with two hands. Faculty have concerns about safety and meeting technical standards. Faculty are doubtful that Sam can transfer life skills to provide safe nursing care.

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From the Disability Resource Professional (DRP) Perspective Sam did not see a reason to disclose until he met with a nursing faculty advisor. While applicants are not expected to disclose a disability during the application process, it is a good idea to do so immediately following acceptance and to reach out to the DRP far in advance of the start of the academic year to discuss the technical standards and skill requirements. The lack of awareness regarding the appropriate processes by faculty is frequently a barrier for the DRP.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might one find information that may lead to appropriate access?

Points of Discussion What Do We Know? Sam has had the disability since birth. Sam has learned to compensate for the lack of two functioning upper extremities. Sam successfully completed 2 years of college without accommodations. Sam graduated with high grades from high school and participates in sports and club activities. Sam is a new nursing student and is required to learn several skills that require two hands. The nursing program has not experienced a situation like this before and is unsure how to support the student.

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What Do We Need to Know? How to work with Office of Disability Services as the resource/keeper of documentation The role of the Office of Disability Services and its responsibility for receiving, storing, and issuing documents pertaining to the student’s disability and accommodations What resources are available at the school to support the student or will external services be needed? How much and what type of accommodations Sam will need or be willing to accept Whether other nursing schools have encountered similar situations How Sam will demonstrate knowledge of and ability in lab and clinical skills Whether Sam can be placed in acute care settings for clinical placements Whether Sam will be able to function effectively and safely in clinical environments Is there anything Sam will need assistance with to perform safely? Does Sam require the assistance of another person? What will be that person’s role? Who would be the best assistant for Sam? How much time could the assistant devote to working with Sam? Which clinical placement is most appropriate for Sam? Which clinical sites will welcome Sam and be willing to provide accommodations? What are requirements of the clinical placement partner? Is the clinical/lab instructor likely to be supportive?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student?

Baccalaureate Program Director Nursing School Dean’s Office Dean of Students/Student Affairs Student Health Center

Discussion Questions 1. At your educational institution, are the technical standards compatible with the Americans with Disabilities Act?

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The school of nursing should evaluate its technical standards to ensure they are not in violation of the ADA. Technical standards should not be the essential functions of a nursing job. They should focus on the student’s intellectual capability to succeed in school and their ability to interact and communicate with others. 2. Are your administrators and faculty aware of the differences between technical standards and essential functions? It is important to make this distinction. Neither prospective nor current students should be evaluated based on essential functions of a nursing job, especially considering that nurses work in a wide variety of settings with differing job expectations. Historically, students have been expected to perform as a nurse in an acute care setting would; however, this is unfair and unrealistic because there are a variety of jobs within and outside of acute care settings. 3. Are your faculty and administrators aware of the recommended process for a nursing school to determine accommodation needs? Faculty cannot ask a student if they have a disability or tell them to go to the Office of Disability Services. Faculty should make all students aware of the process for getting accommodations. Faculty cannot make up their own accommodations. Students must work with a DRP and receive a formal letter listing their accommodations. The student must then give this to faculty who must grant the accommodations. 4. Are your faculty aware of ADA as it pertains to students? Many faculties are unaware of how the ADA applies to students. Schools of nursing should ensure faculty get regular updates to remind them of the law and how it applies to their setting. 5. Do your faculty understand the need to refer to the Office of Disability Services and the procedures surrounding accommodations in their school? It is important that faculty get this information in new faculty orientation and receive periodic updates.

Potential Accommodations for Sam Didactic course Sam has been successful in his prior educational courses without accommodation but another student might value a notetaker

Lab Sam might need the assistance of another student to perform skills requiring two hands, such as a catheter insertion or tracheostomy care

Faculty might consult with occupational therapy or engineering within the college or university to develop a gadget that will assist Sam with twohanded skills

Simulation Simulation is typically conducted in a team. Sam and the other students in his team should discuss the role of each student in the scenario prior to beginning the simulation scenario

Clinical Faculty should consult clinical agencies prior to each clinical placement for Sam to explain what Sam can and cannot do. Faculty will need to advocate for Sam based on his performance in lab and simulation It is important to allow Sam to demonstrate what he can do in the clinical setting and how he can safely compensate for the missing extremity

90 Didactic course Lab Sam should be offered opportunities to show how he can compensate for missing one extremity. In health assessment lab, he may not need any accommodation

L. Neal-Boylan et al. Simulation

Clinical

Guidance from Chap. 10 Faculty cannot ask the student if they have a disability or advise them to go to the Office of Disability Services until the student discloses. Instead, in class or in the course syllabus, faculty should advise all students to seek assistance from the university’s DRP, if they think they have a disability. It is important that faculty understand that the student is not required to disclose on application. While faculty may think the student has a disability, the student may not perceive it that way. Cognitively, Sam should have no problem learning the basic principles of all nursing skills and procedures. Not all typical nursing activities must be performed by a registered nurse. There are activities that the student/nurse can delegate to non-licensed personnel with appropriate training and supervision. Alternative ways of performing tasks are routine in the workplace. It is possible that Sam may require a minimal amount of extra time (as is often the case in clinical situations). If the faculty are concerned about extended time to perform tasks, the DRP may collect data from multiple sources of the actual time it takes to complete certain tasks to determine the amount of extended time that is reasonable. It is the responsibility of the faculty to determine the technical skills required of the student. However, it is the responsibility of the DRP to document and share the accommodations that must be provided to the student. Faculty may not develop their own accommodations for the student. The key to working with Sam, who has had a lifetime of working out his own accommodations, is an understanding that he is the best resource. The faculty should teach Sam the same way they teach all other students, based on the foundational principles that guide nursing actions. These principles center around safe practice. Each student must learn universal precautions, infection control, and proper techniques to ensure patient safety. The faculty should consult Sam as they work together and with the DRP to solve accommodation challenges. Sam should demonstrate how he would carry out the activity, and the faculty should observe and evaluate for safe practice.

Summary Sam’s history of managing tasks with one arm and his ability to manage novel situations will be of benefit in labs and clinical situations. Ideally, the DRP will be providing resources and information about how other healthcare professionals have been successful in accomplishing clinical skills. The DRP works with faculty to

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provide appropriate accommodations to the student. The DRP, Sam, and the faculty work together to develop a plan to address some of the more challenging requirements, such as inserting IVs and Foley catheters. The DRP is in contact with the program faculty to brainstorm ways for the student to accomplish required skills, such as finding time for Sam to work in the simulation lab and conferring with learning specialists and occupational therapists to determine alternate ways of accomplishing tasks. The Office of Disability Services will document and communicate the need for accommodations for this student. The DRP encourages Sam to acquire summer employment at a local hospital to gain experience in performing required tasks. The DRP provides information to the faculty about Federal regulations regarding concerns for patient safety and meeting technical standards to avoid any legal exposure for the program. Specifically, to deny the student an accommodation, the nursing program must be certain that there is documented probability that patient safety will be in jeopardy and conduct an individualized assessment (with a team: DRP, faculty, legal experts, external medical experts) to support that claim. Technical standards should stipulate what the student must be able to perform, with or without accommodation. The technical standards should also include contact information for the Office of Disability Services. This protects the student’s investment in his educational goals and provides resources to the faculty/program in delivering appropriate instruction and evaluation of the student. It is very important that faculty not confuse academic technical standards with the essential functions of nursing work. The academic program is not responsible for admitting or evaluating a student based on whether they can eventually function as a nurse because nurses practice in a variety of settings. Technical standards should only refer to what is required to pass the courses necessary to obtain the nursing degree. If there are alternative ways of performing skills or lifting or moving patients, for example, the technical standards cannot require the student to perform the skill in one way or lift or move the patient alone. The DRP encourages faculty to focus on the performance of the student when discussing placement in clinical sites. There really is no need to discuss the student’s disability until the placement is finalized. The DRP will provide an accommodation notice to the site and/or work directly with the site to implement accommodations. The DRP should be familiar with the site through a prior site visit. The Office of Disability Services will be responsible for the cost of any accommodation. For sites that may express concern, the DRP will work directly with the clinical site disability management team to implement reasonable accommodation(s).

References 1. Ashcroft TJ. Nursing educators’ perspective of nursing students with disabilities [dissertation]. Winnipeg: University of Manitoba; 2012. 1 p 2. Ashcroft TJ, Lutfiyya ZM.  Nursing educators’ perspectives of students with disabilities: a grounded theory study. Nurse Educ Today [Internet]. 2013 [Cited 2013 Nov];33(11):1316–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Nursing+educators%27+p

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erspectives+of+students+with+disabilities%3A+A+grounded+theory+study. https://doi. org/10.1016/j.nedt.2013.02.018. 3. Azzopardi T, Johnson A, Philips K, Dickson C, Hengstberger-Sims C, Goldsmith M, et  al. Simulation as a learning strategy: Supporting undergraduate nursing students with disabilities. J Clin Nurs [Internet]. 2014 [Cited 2014 Feb];23(3–4):402–9. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.12049. https://doi.org/10.1111/jocn.12049. 4. Davidson PM, Rushton CH, Dotzenrod J, Godack CA, Baker D, Nolan MN.  Just realistic expectations for persons with disabilities practicing nursing. AMA J Ethics [Internet]. 2016 [Cited 2016 Oct 1];18(10):1034–40. Available from: https://journalofethics.ama-assn.org/ article/just-and-realistic-expectations-persons-disabilities-practicing-nursing/2016-10. https:// doi.org/10.1001/journalofethics.2016.18.10.msoc1-1610. 5. Horkey E.  Students with physical disabilities: uncovering the process of accommodation implementation in clinical nursing education through grounded theory [dissertation]. Livonia: Madonna University; 2017. 1 p 6. Kritsotakis G, Galanis P, Papastefanakis E, Meidani F, Philalithis AE, Kalokairinou A, et al. Attitudes towards people with physical or intellectual disabilities among nursing, social work and medical students. J Clin Nurs [Internet]. 2017 [Cited 2017 Dec 03];26(23–24):4951–63. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/jocn.13988. https://doi. org/10.1111/jocn.13988. 7. Luckowski A. The lived experience in the clinical setting of nursing students with disabilities. Nurs Edu Perspect [Internet]. 2016 [Cited 2016 Sep/Aug];37(5):256–61. Available from https://www.ncbi.nlm.nih.gov/pubmed/27740556. https://doi.org/10.1097/01. NEP.0000000000000063. 8. Marks B, McCulloh K.  Success for students and nurses with disabilities. Nurse Educ [Internet]. 2016 [Cited 2016 Jan/Feb];41(1):9–12. Available from: https://www.ncbi.nlm.nih. gov/pubmed/26402910. https://doi.org/10.1097/NNE.0000000000000212. 9. McCulloh K, Marks B. Challenges and strategies of nursing students and nurses with disabilities. Nurs News [Internet]. 2016 [Cited 2016];40(1):6–7. 10. Moreland C, Fausone M, Cooke J, McCulloh C, Hillier M, Clifford G, Meeks L.  Clinical accommodations and modifications. In: Meeks L, Neal-Boylan L.  Disability inclusion: disability as diversity. Switzerland, AG. Springer International; 2020. (Chapter 10). 11. Neal-Boylan L. Nurse, physicians with disabilities have similar work experiences: study. Conn Nurs News. 2011. [Cited 2011 Sep-Nov;84(3):16. 12. Neal-Boylan L, Miller M. Treatment like everyone else: the experience of nurses who had disabilities while in school. Nurse Educ. [Internet]. 2017 [Date cited 2017 Jul/Aug];42(4):176–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27922900. https://doi.org/10.1097/ NNE.0000000000000348. 13. Neal-Boylan L, Smith D.  Nursing students with physical disabilities: dispelling myths and correcting misconceptions. Nurse Educ [Internet]. 2016 [Cited 2016 Jan/Feb];41(1):13–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26218008. https://doi.org/10.1097/ NNE.0000000000000191. 14. Oermann M.  Supporting students with disabilities. Nurs Educ [Internet]. 2016. [Cited 2016 Jan/Feb];41(1):1. Available from: https://journals.lww.com/nurseeducatoronline/Citation/2016/01000/Supporting_Students_With_Disabilities.10.aspx; https://doi. org/10.1097/NNE.0000000000000231 15. Shpigelman CN, Zlotnick C.  Attitudes toward nursing students with disabilities: promoting social inclusion. J Nurs Educ [Internet]. 2016 [Cited 2016 Aug];55(8):441–9. Available from https://www.ncbi.nlm.nih.gov/pubmed/27459430. https://doi. org/10.3928/01484834-20160715-04. 16. Students’ virtual internship helps build network and boost confidence. Learn Disabil Pract. [Internet]. 2019. [Cited 2019 Mar 25];22(2):7. Available from: https://journals.rcni.com/ learning-disability-practice/news/students-virtual-internship-helps-build-network-and-boostconfidence-ldp.22.2.7.s6/abs. https://doi.org/10.7748/Idp.22.27.s6.

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17. Symes J.  Nursing students with disabilities in the clinical setting: nursing education leaders’ perceptions of accommodations [dissertation]. Vermillion: University of South Dakota; 2014. 1 p 18. Zlotnick C, Shipigelman CN.  A 5-step framework to promote nursing community inclusivity: the example of nurses with disabilities. J Clin Nurs. [Internet]. 2018 [Cited 2018 Oct];27(19–20):3787–97. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/ jocn.14566. https://doi.org/10.1111/jocn.14566.

Resources Exceptional Nurse. www.exceptionanurse.com. National Council of State Boards of Nursing. National Organization of Nurses with Disabilities. www.nond.org. Nurses with disabilities. Job Accommodation Network. https://askjan.org/topics/Nurses.cfm. You Tube video series: Eileen Quinn, RN. How to insert an IV with one hand, giving injections with one hand.

The Student with a Sensory Disability: Anna Howard, a Deaf Nursing Student

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Stacey M. Carroll, Carrie Morgan Eaton, and Marie Lusk

Case History Anna Howard is a sophomore nursing student who has a bilateral hearing loss in the range of profound deafness (90–110 decibel loss). She was likely born deaf and was diagnosed at age 2, so she is considered “prelingually deafened” meaning she became deaf before language was achieved. Her family members and social circle are hearing. Anna was raised to communicate via speaking and lipreading. She speaks intelligibly albeit with a discernable speech difference. She does not know or desire to learn sign language and does not consider herself a member of the deaf culture. Anna wore a hearing aid in one ear which allowed her to hear some noises, but lipreading is her primary means of understanding the spoken word. Her other ear does not benefit from a hearing aid. Anna’s audiogram results remained stable until one point in her teens when she had a sudden drop in hearing. At that point, Anna received a cochlear implant in the ear in which she previously wore a hearing aid. She graduated near the top of her high school class. Anna enrolled in a large state university as a pre-nursing major with a goal to earn a Bachelor of Science degree in Nursing (BSN) and pass the national nursing licensure board examination (NCLEX). She did not have any formal accommodations in the pre-nursing program but informed her faculty at the start of each semester that she lip-reads and would position herself in the front of the classroom. She

S. M. Carroll (*) Rush University College of Nursing, Chicago, IL, USA C. M. Eaton University of Connecticut, Storrs, CT, USA M. Lusk Rush University, Chicago, IL, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_10

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independently arranged to make copies of a classmate’s notes. She was not in contact with the Office of Disability Services during her first year. Students with the top 30 grade point averages (GPAs) at the end of freshman year, when the pre-nursing curriculum was completed, were admitted to the nursing program. The technical standards of the program stated, “Student must be able to hear.” At the conclusion of her freshman year, Anna’s GPA was a 3.97 placing her in the top 30 GPA standing, guaranteeing her a spot in the nursing program. Anna applied for the program and was denied entrance. Anna appealed the decision to the dean. Upon review of the program requirements and Anna’s grades, the dean found that Anna qualified for the BSN program and admitted her. had never admitted a student who was Deaf or Hard of Hearing (D/HH). Neither the program nor Anna had previous contact with a nurse or nursing student who was deaf. To provide additional support to the student and to address barriers that may arise in the nursing program, the dean referred Anna to the Office of Disability Services. Anna was asked to submit an application for accommodations, a copy of her audiogram records, and a healthcare provider statement to the Disability Resource Professional (DRP) for review. The DRP began the interactive process by setting up a meeting with Anna. The DRP inquired whether Anna required communication access real-time translation (CART) services or interpreter services (American Sign Language [ASL] or oral), so she could reserve assistive services prior to their first session (https://dhcc.org/interpreting-services/cart/) [1]. Anna shared with the DRP that she does not know or utilize ASL, nor would she require an oral interpreter or CART for this one-to-one meeting because lipreading is her primary means of understanding spoken words and she communicates by speaking. The goal of the first session was to introduce Anna to how the accommodation process functions, identify the DRP as Anna’s new point person to discuss barriers she encounters based on her disability, review the remaining nursing curriculum— including technical standards/essential functions—in detail, and discuss what barriers might present themselves during the remainder of her program. The DRP used ASL while speaking during the meeting, and Anna educated her that she does not know ASL and that using ASL was distracting because it impeded her ability to lip-­ read. Eventually the DRP connected with the nursing department, including the simulation laboratory coordinator (SLC), to address the clinical barriers the student brought forth and engaged them in the interactive process for additional faculty buy­in to the accommodation process.

Perspectives Barriers from the Perspective of Student I am concerned about note-taking because of the need to lip-read lecturers. I know that notetaker reliability and quality varies. I am anxious about being able to find my own notetakers. I am worried the professors will mumble or turn away or have heavy accents.

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How will I lip-read wearing standard surgical masks? I feel sad because of the negative attitudes of others about my becoming a nurse. I feel constant pressure to excel and prove myself. I do not think I will be able to hear using a traditional stethoscope. I am not even sure yet what accommodations I will need for clinical [2]. I think the technical standards in place may be outdated and exclusionary [3]. How will I lip-read high-fidelity manikins in the simulation lab? They talk but their lips do not move. I feel frustrated with my difficulty communicating with the DRP because the DRP used a means of communication (ASL) I do not know. How will I handle audio questions provided to prepare for the NCLEX? I worry that I may not get hired after graduation and be accepted by the nursing profession. I do not have any social interaction with other nurses who are deaf, to learn from their experiences.

Barriers from the Perspective of Nursing Program The faculty are concerned about not being able to place Anna in a clinical rotation since clinical agencies can be resistant to having a nursing student who is D/HH. The faculty express concern about Anna not hearing alarms and not being able to take vital signs using a stethoscope. The faculty have concerns about Anna meeting the technical standards, and they are conflicted between technical standards and accommodations. The faculty is unsure whether clinical assignments can or should be modified. The faculty is uncertain whether Anna will get a job after graduation. The faculty have a lack of knowledge about accommodations (classroom, clinical, and simulation lab) and associated resources.

 arriers from the Disability Resource Professional B (DRP) Perspective The student has never utilized accommodations and does not know the process. The DRP does not know how the student communicates (speaking/lipreading, CART, ASL). The DRP is unaware of faculty experience working with students who are D/HH. The DRP does not know what barriers a student who is D/HH would face in the clinical setting throughout the program. The university’s technical standard language is outdated and discriminatory. The DRP does not know what barriers the student may face when participating in evaluations utilizing standardized patients (SP) and/or objective structured clinical examinations (OSCE). The DRP does not know if campus student groups (such as the Student Nurses Association) are accessible to this student.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

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Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know? The faculty and administration in the nursing program have no experience with a student who is D/HH. Anna has had a lifetime of being deaf and is a creative self-advocate but is not aware of all the resources available to her or what is required for the on-­ campus (simulation) and off-campus clinical portions of program. Anna is motivated and a strong student but finds it stressful to need to prove herself. Anna must be able to lip-read in order to follow what is being said. Clinical rotations will be beginning and will increase in complexity as the program progresses. Clinical agencies cannot deny a student on the basis of a disability. Modifications can be in the form of reasonable accommodations; the student and DRP are resources for learning about these accommodations. Anna cannot hear through a traditional stethoscope. Anna cannot lip-read through a traditional surgical mask. Safety is often a concern of nursing faculty and other nurses despite lack of research demonstrating any safety concerns regarding nurses with disabilities [2]. The college is responsible for paying for reasonable accommodations under the Americans with Disabilities Act (ADA). Simulation laboratory experiences (e.g., high fidelity, virtual simulation, etc.) can count for a certain percentage of clinical experience time [4], depending on state (https://www.inacsl.org/simulation-regulations) [5]. On-campus clinical using high-fidelity simulation requires accommodations because faculty engage as the voice of the manikin through a remote audio system. The nursing faculty role is to focus on program requirements and providing foundational education; ensuring the student obtains a job postgraduation is beyond faculty scope.

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What Do We Need to Know? Are there ways to educate clinical sites/staff and nursing faculty about having a nursing student who is deaf to reduce their resistance, promote acceptance, and correct erroneous assumptions regarding safety concerns? Is there access to practicing deaf nurses who can share their experiences with Anna, the DRP, and the faculty? Will the amplified stethoscope work for Anna, or would a visual (digital screen reader) stethoscope be preferable? What new stethoscope options are being developed? How will the operating room rotation be modified to meet Anna’s needs? Are there other options to having a classmate take notes? Is the simulation laboratory accessible? Has there been discussion with the simulation laboratory coordinator and the DRP and the student? Does the DRP understand clinical requirements and accommodations specific for nursing? Is Anna’s competency being evaluated on the same basis as her non-­ accommodated peers? Is task-trading or teamwork a reasonable accommodation?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for this Student? Nursing program director for enhanced review of the BSN program requirements and relevant clinical and simulation faculty/staff. Nursing clinical scheduling coordinator to discuss appropriate clinical placements/sites SLC to address scheduling and use of SP and/or script during manikin simulations so a process can be determined before student’s first simulation visit Financial Aid Department regarding cost coverage for any assistive technology. [Note: some DRP offices cover costs while others have students discuss with financial aid; this is university specific.]

Discussion Questions 1. At your educational institution, are there technical standards or essential functions?

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The academic program should not assess or measure student competencies based on the essential functions of a nursing job. Rather, they should use ADA-­ compliant technical standards that pertain only to academic success. The DRP and program directors should be aware of the school of nursing’s technical standards. Technical standards should be reviewed annually by faculty, administrators, and the DRP to account for any program changes and to ensure there is no discriminatory language that would deter students from applying for the program and that would showcase the institution’s commitment to inclusivity. Technical standards should be posted online for quick reference and for prospective students to review. This can aid in starting discussions with relevant stakeholders early, in case prospective students are concerned they may encounter barriers. In this case study, the technical standards language is outdated and discriminatory stating “student must be able to hear.” The technical standards should not focus on sensory ability but rather on outcomes. Ways to meet the outcomes can be creative and varied. Communication is a more relevant and appropriate outcome. This student can communicate effectively with her faculty, peers, and patients. 2. Does your institution have a student-centered approach to valuing disability as diversity? Diversity is often discussed with respect to racial/ethnic/sexual orientation issues, but disability is also a part of a diversified institution. Institutions that value disability will place primacy on the person with a disability’s input on what works for him/ her. This person should be approached as a valued equal member of the institution. 3. What are some resources your faculty/ DRP can give students who are D/HH? Frequently, both the faculty and the student with the disability are unaware of all the resources available, especially with regard to clinical and simulation laboratories. Anna should be referred to the National Organization of Nurses with Disabilities (www.nond.org) [6] who may be able to connect Anna with practicing nurses who are deaf, making her feel less isolated and more supported. A referral could also be made to the Association of Medical Professionals with Hearing Losses (www.amphl.org) [7] to obtain resources for a modified stethoscope and connect with others who are D/HH.  For specific accommodation resources related to technology, Connect Hear (http://connect-hear.com) [8] provides up-­to-­date solutions, developed in response to the COVID-19 pandemic where widespread use of masks inhibits communication by those who lip-read. An institution’s student life department can provide all students with resume writing workshops and interviewing practice sessions to aid in job searches upon graduation and licensure. The DRP could also reach out to DRPs at other institutions to link Anna with a fellow student navigating a nursing program who utilizes speaking and lipreading.

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Potential Accommodations for Anna Lab Anna will be granted consistent time in the lab to practice utilizing any/all new assistive technology such as an adaptive stethoscope (purchased by the DRP office) prior to attending clinical. This comparison table of stethoscopes can be used to help Anna find the one that works best for her: https://www. amphl.org/comparisontable [7]. Anna is to contact the simulation center director to schedule practice sessions which can include additional lab sections during the week and/or open lab sessions to refine her skills if needed. Peer-to-peer skills If there is a choice development is a between two professors, assign Anna program supported by to the one who is easier https://www.laerdal. com/us/learn/ for her to lip-read. peer-to-peersimulation/ [9] where students use a tablet (Laerdal SimPad) to train each other without the direct oversight of a facilitator. This will allow Anna to learn in small group interactions (2–3 students) versus larger groups (8–10) that are generally seen in low-fidelity simulation labs.

Didactic course In-person lecture faculty are to speak facing Anna while lecturing so she has a line of sight and can lip-read. If lectures use an online via video platform, the lecturer will ensure adequate high-quality connection, face the camera, and ensure the volume is adequate so that the information can be picked up by captioning processes used by the student. If students are asking questions, the lecturer (in-person or via video) should repeat the student question.

Simulation A script can be provided for Anna to read what is being stated by the high-­ fidelity manikin, or a simulation staff member could repeat what the manikin says. Alternatively, Anna could use an automated captioning application on her phone (e.g., Live Transcribe for Android, Otter.ai for iPhone); other possibilities can be found at http:// connect-hear.com). Anna should be given the choice on which accommodations work best for her.

Clinical Faculty will explain to clinical site point people that Anna can effectively communicate with patients and perform skills with accommodations and will advocate for her inclusion.

Online streaming videos can be used prior to hands-on practice and could be adapted to include captioning.

In settings where surgical masks are worn, all required providers will wear clear see-through masks when student is present. Masks can be ordered through Safe ‘N Clear by DRP (https://www. safenclear.com) [10]. Student will be positioned in place where she can see providers to lip-read.

102 Didactic course Anna is permitted to record class lectures and guest lectures via Sonocent (www. sonocent.com) [11] and/or Dragon Speak (https://www.nuance. com/healthcare/ provider-solutions/ speech-recognition. html) [12] software. Both programs facilitate note-taking, scribing, and recording and eliminate the need for a classmate’s copy of notes. These programs allow Anna to organize lectures in a way that works best for her learning style. Licenses to be purchased by DRP office and issued to Anna for the duration of the academic program; student can determine which program is best for her. All recordings are for Anna’s personal use only and will not be shared with others. In the event of audio recordings used during examinations, captioning will be provided. If announcements are made during examinations, instructor/proctor will ensure Anna is aware of the announcement.

S. M. Carroll et al. Lab Anna can request video recordings of the simulation lab demonstration, as well as video recordings of herself performing a skill. For the latter, she can request faculty annotate her performance followed by a debriefing session where she can playback the recording and view the notations. Various learning management systems (LMS) [13] are dedicated to capturing recording and faculty annotations for debriefing (see resources list).

Simulation Anna can practice on a SP in lieu of high-­ fidelity manikins. Students can play the role of embedded participants to enable Anna to lip-read during the sessions. The simulation center can establish a volunteer SP program allowing healthcare students who require volunteer opportunities the chance to augment their resume. DRP office would cover charges for extra staff time in the simulation lab.

Clinical During clinical post-conferences, whoever is speaking will hold a small ball, providing Anna with a visual cue regarding who is speaking.

Student will create a system with oriented patients to press the call light when any machinery beeps or alarms sound in the patient’s room. This would alert the student to assess the situation. If the patient is not able to press the light, student will be paired with another student or staff member to be alerted.

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Guidance from Chap. 7 [14] The use of simulation has become an integrated part of undergraduate nursing education with a focus on experiential learning in small groups. Simulation education facilitates nursing students’ mastery of skills and enhances their overall confidence. Without advanced planning, students with disabilities face significant challenges in a variety of learning environments (see Chap. 7). For example, during high-fidelity simulation, faculty remotely operate simulation manikins to depict complex patient case scenarios. Students hear the voice of the simulation facilitator or operations specialist who is portraying the role of the patient through a microphone in the manikin, bed, or wall. The challenging interaction between the programmable human patient simulator (manikin) and the student(s) teaches student nurses to respond to both fundamental and critical healthcare situations. The remainder of the class observes the simulation via a livestream video or through a two-way mirror connecting to an external observation room. Some of these innovative, high-­ technology instructional methods create unintended obstacles for students with disabilities (see Chap. 7). For Anna, simulation presents barriers and enablers: Simulation modality Human patient simulator (manikin) in high-fidelity simulation Observation via livestream audiovisual technology (LMS)

Observation via a two-way mirror with microphone

Barriers(s) Voice of the manikin stems from computer-generated sounds or via a simulation facilitator using a microphone to portray the voice of the simulated patient

Enabler(s) Physiologic responses (e.g., heart sounds, lung sounds) are programmable (normal or abnormal) and the sounds have various volume settings that can be adjusted, if helpful The simulation facilitator and/or Audiovisual quality plays a significant faculty member has the ability to role in the observer’s experience annotate valuable learning points Students engaged in the simulation will be multitasking and not speaking directly to review in the debrief. These into the camera where Anna is observing annotations can be made directly visible to Anna during the livestream or reviewed in detail during the debrief. Faculty have the ability to capture their voice into a captioning program during the livestream for Anna when she is in the observer role The observation room needs to be dimly Anna would have the opportunity to visualize peers without the lit or dark in order for the two-way pressure of seeing her present. mirror to work. The mirror is space limited and may not cover the parameter This reciprocates for Anna; she can be working through scenarios of the observation room. This makes it without the pressure of being able difficult for Anna to read lips. Sound to see who is watching control (leakage) is an issue if soundproofing isn’t done properly on installation

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Barriers(s) The instructor often demonstrates nursing skills such as inserting an indwelling urinary catheter on a manikin. Students gather around the instructor who speaks while focusing on accomplishing the skill. This makes it difficult for Anna to understand the instructions

Enabler(s) Manikins allow students repetitive practice to develop and refine skills. Anna can have a live translation program available on her phone during the demonstration. Another option is peer-to-peer learning where a tablet is used to demonstrate the skill and peers evaluate each other. Anna will benefit from working one on one with a peer. This will establish an active learning process for Anna, which is conducive to successful learning (see Chap. 7)

Carroll and Eaton [15] expressed the importance of universal design in the simulation laboratory as a way to respect diversity and increase accessibility. Universal design is a proactive approach where the cause of inequity is addressed as a whole (see Chap. 7) and the entire process is changed rather than the focus being on one specific person. In this way, all students—with or without disabilities—benefit from the more inclusive overall process. Respecting diverse abilities in nursing education is a culture change that needs to be evaluated in simulation laboratories as nursing schools continue to replace or supplement off-campus clinical with on-campus clinical in simulation.

Summary A copy of Anna’s accommodations was emailed by the DRP to relevant faculty and clinical instructors prior to the start of the new semester. During her first clinical rotation, while providing patient care, Anna notified her patients of her deafness and reminded them to face her when speaking so she could lip-read. She teamed up with another student who notified her if a patient’s alarm was sounding. Anna also found creative ways to ensure she was not missing sounds. For example, she would request that an oriented patient press the call light button when the intravenous pump beeped, and this would alert her to assess the situation. Anna found that her patients were receptive to having her as a student; no patient declined to have her as a student nurse. During her educational process, the COVID-19 pandemic occurred, resulting in courses temporarily being moved to online lectures and schools converting to virtual simulation as a method of clinical replacement. Upon return to clinical, all healthcare staff were wearing masks, presenting an increased barrier to lipreading in all clinical settings. This new unprecedented educational landscape required flexibility, creativity, collaboration, and patience for all involved. Finding solutions took on added urgency, requiring teamwork.

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Some clinical instructors were unconvinced that Anna could successfully accomplish clinical rotations and made this clear to her at the outset. Other instructors kept their reservations to themselves until her final evaluations in which they explained their initial hesitations but were pleased that Anna had surpassed their expectations and had done well. One instructor insisted that Anna demonstrate competencies that her peers did not have to demonstrate. Anna brought this to the DRP’s attention. The DRP intervened and explained that Anna needs to be evaluated in the same way as her peers to meet program outcomes and should not be expected to do more to prove herself. Some nursing students and peers were supportive, while others conveyed subtle skepticism that Anna could be a nurse. Anna continued to check in with the DRP throughout the remainder of her program to discuss any additional barriers that presented themselves. The DRP offered to provide the nursing program training on working with students with disabilities in all areas of their educational experience and to address the issue of negative attitudes of faculty toward students with disabilities as well as correcting erroneous perceptions of safety concerns. The DRP also addressed the outdated technical standard that stated, “Student must be able to hear.” The DRP cited institutions that have moved away from this exclusionary language. The DRP explained that Anna can communicate by speaking and lipreading and that she has accommodations for auditory elements of the program, allowing her to meet objectives. The DRP used case studies with nursing faculty and clinical sites to demonstrate creative access approaches. Accommodations were approved and implemented for Anna through the interactive process by the DRP, student, relevant clinical faculty, and simulation laboratory coordinator. Anna completed the program, graduated summa cum laude, and passed the NCLEX on the first try.

References 1. Deaf Hearing Communication Centre, Inc. Available at: https://dhcc.org/. 2. Neal-Boylan L, Smith D.  Nursing students with physical disabilities: dispelling myths and correcting misconceptions. Nurse Educ. 2016;41(1):13–8. 3. Ailey SH, Marks B. Technical standards for nursing education programs in the 21st century. Rehabil Nurs. 2017;42:245–53. 4. Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. The NCSBN national simulation study: a longitudinal, randomized, controlled study replacing clinical hours with simulaiton in prelicensure education. J Nurs Regul. 2014;5(2):C1–S64. 5. INACSL Simulation Regulations Committee: simulation regulation map. Available at: https:// www.inacsl.org/simulation-regulations/. 6. National Organization of Nurses with Disabilities. Available at: https://nond.org/. 7. Association of Medical Professionals with Hearing Losses. Available at: https://www. amphl.org/. 8. McNally C, Childress T. Connect hear. Available at: https://connect-hear.com/knowledge-base/. 9. Laerdal medical peer to peer skills development. Available at: https://www.laerdal.com/us/ learn/peer-to-peer-simulation/. 10. McIntosh A. Safe ‘N’ clear: the communicator surgical mask™. Available at: https://safenclear.com/. 11. Sonocent Ltd. 2019. Available at: https://www.sonocent.com/. Accessed 27 Apr 2020. 12. Nuance Communications, Inc. Available at: https://www.nuance.com/dragon.html.

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1 3. CAE Healthcare: LearningSpace. Available at: https://caehealthcare.com/learningspace/. 14. Petersen KH.  Increasing accessibility through curricular design. In: Meeks L, Neal-Boylan L. Disability inclusion: disability as diversity. Switzerland, AG. Springer International; 2020. (Chapter 7). 15. Carroll SM, Eaton C. Accessible simulation: a necessity in nursing education. J Nurs Educ. 2019;58(11):619–21.

Suggested Readings Maheady D. Exceptional Nurse, Inc. Available at: http://www.exceptionalnurse.com/index.php. Association on Higher Education and Disability (AHEAD). 2020. Available at: https://www. ahead.org/home. Accessed 27 Apr 2020. Coalition for Disability Access in Health Science Education. 2020. Available at: https://www. hsmcoalition.org/. Accessed 27 Apr 2020. Society of Healthcare Professionals with Disabilities. 2019. Available at: https://www.disabilitysociety.org/. Accessed 27 Apr 2020. Rush University: Technical Standards for College Students. Available at: https://www.rushu.rush. edu/technical-standards-college-nursing-students. National Council of State Boards of Nursing, Inc. Available at: https://www.ncsbn.org/index.htm. Rutherford-Hemming T, Lioce L, Kardong-Edgren S, Jeffries PR, Sittner B. After the National Council of State Boards of Nursing simulation study—recommendations and next steps. Clin Simul Nurs. 2016;12(1):2–7. International Nursing Association for Clinical Simulation in Learning (INACSL): standards of best practice: simulationSM. Available at: https://www.inacsl.org/ inacsl-standards-of-best-practice-simulation/. Inacsl SC. INACSL Standards of best practice: simulationSM simulation design. Clin Simul Nurs. 2016;12:S5–S12. Society for Simulation in Healthcare Certified Simulation Educator Examination Blueprint. Available at: https://www.ssih.org/Certification/CHSE/Exam-Information. B-Line Medical – a Laerdal Company: SimCapture. Available at: https://blinemedical.com/simcapture.html.

Resources

Disability-Related Resources AHEAD: Association on Higher Education and Disability: www.ahead.org Committed to full participation in higher education for people with disabilities. Association of Medical Professionals with Hearing Losses: http://www.amphl.org/ Brings together professionals with hearing loss from various healthcare fields and facilitates online networking/ mentorship. AMPHL has resources on stethoscopes and offers conferences. AMPHL has been instrumental in advocating for the manufacture of a see-through surgical mask, which is now available for purchase through a third-party vendor (https://www.safenclear.com/). Coalition for Disability Access in Health Science and Medical Education: http://hsmcoalition.org Focuses on improving experience with accommodations in graduate health science and medical education programs. Connect Hear: http://connect-hear.com List of strategies for D/HH communication including videoconferencing, captioning, and assistive technology. Exceptional Nurse: http://www.exceptionalnurse.com

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Committed to the inclusion of more people with disabilities in the nursing profession and offers a way to share information and resources. National Organization of Nurses with Disabilities: http://www.nond.org Promotes equity for people with disabilities in nursing through education and advocacy. NOND provides resources to nursing students, nurses, DRPs, and employers. Society for Healthcare Professionals with Disabilities: http://www.disabilitysociety.org Provides an online community and disability-related resources for healthcare professionals with disabilities.

Technical Standard Resources Rush University Technical Standards: https://rushu.rush.edu/technical-standards-college-nursing-students Rush University in Chicago underwent an institution-wide review of their technical standards in 2017 to remove any exclusionary language so prospective and current students have a clear understanding of their nondiscriminatory program requirements. Example of exclusionary language used in many institutions’ technical standards: “speak” instead of the preferable “communicate.” Communication may or may not involve speaking. Technical Standards for Nursing Education Programs in the 21st Century by Sarah H.  Ailey PhD, RN, CDDN, APHN-BC and Beth Marks PhD, RN https://onlinelibrary.wiley.com/doi/ full/10.1002/rnj.278 Outdated technical standards or program standards can be another barrier prospective students may face upon application to health science programs.

Simulation Resources Association of Standardized Patient Educators. https://www.aspeducators.org/ Resource for people who are Standardized Patient Educators. ASPE Standards of Best Practice. International Nursing Association for Clinical Simulation and Learning. https://www.inacsl.org/simulation-regulations/ Site has an interactive map whereby users can determine Board of Nursing regulations for simulation state-by-state, as they vary. Rationale, outcomes, criteria, and guidelines for implementing the INACSL Standards of Best Practice: SimulationSM. Learning Management System (LMS) examples dedicated to capturing recording and faculty annotations for debriefing include, but are not limited to: SimCapture by Bline-Laerdal: https://blinemedical.com/simcapture.html?gclid=EAIaIQobChMI7 ou3u6v96AIVTV8NCh2PJwl1EAAYASAAEgK9LfD_BwE CAE Learning Space LMS: https://caehealthcare.com/learningspace/ National Council of State Boards of Nursing: https://www.ncsbn.org/685.htm Resource for clinical simulation in nursing. Their landmark large-scale longitudinal randomized control trial showed that up to 50% of clinical can be effectively substituted with high-fidelity simulation. Recommendation and next steps following the NCSBN landmark study include, but are not limited to, a dedicated simulation team, debriefing based on a theoretical framework, research to demonstrate evidence of simulation outcomes, and ongoing professional development for simulation educators. Society for Simulation in Healthcare (SSIH) Examination Blueprint: https://www.ssih.org Provides a blueprint for the process of becoming a Certified Healthcare Simulation Educator (CHSE).

The Student with a Psychological Disability: Melanie Mathews, a Nursing Student with Suicidal Ideation

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Leslie Neal-Boylan, Michelle D. Miller, and Jan Serrantino-Cox

Case History Melanie Matthews is currently in the second semester of her sophomore year in the baccalaureate nursing program at a private university. She has a scholarship for which she must maintain a 3.0 GPA, a condition she has managed, just barely, to meet, with a cumulative GPA of 3.1 after her first three semesters. Melanie has never had any difficulty learning but finds her nursing courses to be very challenging, and she is extremely worried about losing her scholarship, without which she could not afford her tuition and living expenses. As her anxiety increased, Melanie began to have days when she felt so paralyzed with worry that she could not get out of bed in the morning. This caused her to miss class on several occasions. She also began to cut herself to relieve her anxiety and told several other students that she just did not know if life is worth living. Finally, one evening, a friend found Melanie on the floor of her room unconscious with an empty pill bottle next to her and immediately called 911. When she woke up in the hospital, Melanie realized that she needed help and had herself voluntarily committed for psychiatric care. After 2 weeks of treatment, Melanie felt much better. She has been diagnosed with anxiety and depression and has been placed on appropriate medication. She has also received counseling, which

L. Neal-Boylan (*) Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA M. D. Miller Quinnipiac University, Hamden, CT, USA J. Serrantino-Cox Coalition for Disability Access in Health Science Education, Rancho Santa Margarita, CA, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_11

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she intends to continue when she returns to campus. For the first time in a long time, Melanie feels optimistic that she can meet the challenges of nursing school. However, when Melanie’s mom picked her up after her discharge from the hospital, she told Melanie that she had received a letter notifying her that she has been placed on medical leave from the university and may not return until the next semester and she may only return then if she can prove that she does not present a danger to herself or others. Melanie wants to appeal this decision, but the letter does not mention how to do so or whom to contact for information. Melanie wrote a letter to the dean of the school of nursing asking to be reinstated immediately. She explained that she has been diagnosed with anxiety and depression but now has her condition under control. She also requests an accommodation of time and a half on exams, since timed test taking exacerbates her anxiety. Upon receipt of the letter, the dean requests a meeting with the Vice President of Student Development to discuss the matter. At this meeting, the dean admits to the vice president that the nursing faculty is worried that Melanie poses a danger to herself and may pose a danger to patients when she begins her clinical rotations in the fall. Some of the faculty have voiced a concern that someone who is not “mentally stable” is not a good candidate to become a nurse, as it is a very stressful job. The vice president agrees that Melanie should not be allowed to return to campus until she can provide documentation from a mental health professional that she no longer poses a risk to herself or anyone else. She sends Melanie a letter, denying her “appeal.”

Perspectives Barriers from the Perspective of the Student I have wanted to be a nurse since I was 8 years old, and I feel like my dream is about to die. I am frustrated that I was withdrawn from my courses without any opportunity to meet with my professors to explain that I am doing much better and only need a little more time taking exams to succeed. I am worried that now that I am not allowed to return to campus, everyone will find out that I have been in the psychiatric ward for 2 weeks. I think that everyone including my friends, the students, and the faculty will think I am “crazy.”

Barriers from the Perspective of the Nursing Program Melanie failed to tell anyone, including her advisor, that she was having trouble. This can be a barrier to nursing faculty trusting that Melanie will come to them should she ever experience symptoms again. The faculty is concerned about whether Melanie can handle the stress of nursing school and then employment as a nurse after she graduates. The faculty wonders if Melanie can provide safe patient care. The faculty are unsure how best to support the student.

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From the Disability Resource Professional (DRP) Perspective Neither the dean nor vice president consulted Disability Resource Services before telling the student their decision. There are procedures in place for determining when a student can be involuntarily withdrawn from the program. If I had been contacted before the decision was made, I would have met with the student and faculty to determine reasonable options. Both the nursing program and the student seem unaware of the resources available to them on campus and that a DRP should be consulted in situations like this.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you already know? What more do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Already Know? Melanie has a lifelong dream of a nursing career. Melanie has been suffering from anxiety, stress, and financial worries for some time. Melanie has a recent history of cutting herself and attempted suicide. Others are aware of Melanie’s attempted suicide. Melanie recently received care for anxiety and depression and is now on medication for her condition and is receiving counseling. Melanie has requested time and a half for exams as an accommodation for her anxiety. Melanie is optimistic that she can handle the rigors of the nursing program as long as she remains on medication, continues with counseling, and can receive extra time for taking examinations. The nursing program has not experienced a situation like this before and is unsure how to support the student.

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What More Do We Need to Know? Is anxiety or depression a “disability” under the Americans with Disabilities Act? Does Melanie pose a “direct threat” to herself or others? What are the legal requirements for an initial hearing or an appeal involving the involuntary withdrawal of a student with disabilities? How can the Disability Resource Center serve as the resource/keeper of documentation? What resources are available at the school to support the student or will external services be needed? Is time and a half on exams a “reasonable” accommodation in Melanie’s case? Are there other reasonable accommodations that could help mitigate Melanie’s anxiety? Have other nursing schools encountered similar situations? Will Melanie be able to function effectively and safely in clinical environments?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? Nursing School Dean’s Office Nursing faculty Dean of Students/Student Affairs Counseling Center Student Health Center Letter from the student’s healthcare provider United States Department of Education, Office for Civil Rights The Bazelon Center for Mental Health Law www.bazelon.org National Organization of Nurses with Disabilities wwwnond.org Exceptional Nurse www.exceptionanurse.com National Council of State Boards of Nursing

Discussion Questions 1. Are the educational institution’s procedures for involuntarily withdrawing a student compatible with the Americans with Disabilities Act? What about their appeals process? The university should ensure that they have instituted proper procedures for determining whether a student should be involuntarily withdrawn. They must also create an appeals process that ensures students receive the required due

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process, including the right to request immediate reinstatement. Consultation with a disability lawyer is appropriate. 2. Are faculty aware of the ADA as it pertains to students? Many faculty members are unaware of how the ADA applies to students. Schools of nursing should ensure faculty get regular updates to remind them of the law and how it applies to their setting. 3. Do faculty understand when they should refer a student with disabilities to the Office of Disability Services? Although it is not appropriate to ask a student if they have a disability, it may be a good idea in certain circumstances to ensure that a student is made aware that there is an Disability Resource Center on campus to which they may turn to request accommodations. 4. Are faculty familiar with the procedures surrounding accommodations in their school? It is important that faculty get this information in new faculty orientation and receive periodic updates.

Potential Accommodations for Melanie Didactic course Melanie has requested time and a half to take examinations, as timed tests worsen her anxiety

Lab For those skills requiring speed, Melanie might require an accommodation of extra practice time so she can master the skill before she must complete it in the presence of others

Simulation Practicing certain skills in the simulation lab before performing them in clinical or in testing might reduce Melanie’s anxiety

Clinical Melanie may need an accommodation for time and a half to complete procedures or charting, if this doesn’t jeopardize patient safety

Guidance from Chaps. 1, 5, 12, and 13 Chapter 1 from Disability Inclusion: Disability as Diversity is very informative for this case. The chapter discusses the frameworks for disability inclusion and reminds us that the language of the legislation is broad with the potential for multiple interpretations. Programs are not expected to “fundamentally alter their standards in order to include learners with disabilities.” However, as the authors in Chapter 5 note, mental health concerns are common for students in health sciences programs, such as nursing and medicine. Thus, it makes a great deal of sense to support all students with thoughtful, student-centered wellness programming to prevent some of the anxiety and depression that is common for students in these high-stress programs. Social support including the promotion of learning communities is key and should be proactive. When students do struggle, they should be identified and referred to mental health services. For some of these students, it may be necessary to take a medical leave of absence from their program. In such a case, it is very important that the leave policy itself does not create a barrier, which can happen when fees are charged, when

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the student must gather multiple signatures, or when the student will have to reenroll when they are ready to return. Such hurdles can cause the student desiring to take a medical leave to feel punished and may dissaude a student who would benefit greatly from taking a break to address their mental health concerns. Of course, it is always possible that a student will need to be involuntarily placed on a medical leave. Health Science programs are often concerned about the possibility that a student suffering from a psychological disability may constitute a danger to the health or safety of patients, other students or themselves. And indeed the ADA expressly excludes persons who pose a “direct threat” to the safety of others from the definition of “otherwise qualified.” Chapters 12 and 13 consider the “direct threat” exception as it applies to medicine and nursing, respectively. The authors in both chapters explain that the ADA defines “direct threat” as “a significant risk to the health or safety of others that cannot be eliminated by reasonable accomodations” (42 U.S.C. § 12.111(3)). The authors go on to note that, although the statutory language only applies to “others,” the regulatory agencies in charge of administering Title II (the Office of Civil Rights of the Department of Education) and Title III (Department of Justice) of the ADA, have made it clear that the same sort of individualized assessment must be conducted whether the risk the student potentially poses is to self and/or to others. The authors of chapter 12 present an excellent, recent example of the regulatory requirements that must be met before a university can involuntarily place a student on medical leave. In the case presented, the University of Tennessee Health Science Center (“UTHSC”) involuntarily placed a student with a mental health disability on a medical leave of absence. The Department of Justice required that the UTHSC modify its policies to ensure that an individualized assessment is conducted that includes current medical information or, in the absence of such information, that the best available objective evidence is considered, before a student can be involuntarily placed on medical leave. The Department of Justice also directed that, if the health or safety of the student or others is a concern, a direct threat assessment much evaluate the nature, duration, and severity of the risk, as well as the likelihood of such an occurrence. Moreover, the assessment must address the question of whether there are any reasonable modifications that can be made to policies, practices, or procedures that would mitigate the risk. After the requisite individualized assessment is conducted, a student may only be involuntarily placed on a medical leave if required accommodations are unreasonable or would fundamentally alter the nature of the program; or if the student rejects reasonable accommodations; or if the student would fail to meet program eligibility requirements, even were reasonable accommodations provided. Chapter 12 thus makes clear that health science programs must carefully craft their involuntary medical leave policies in such a way that a student’s rights under the ADA are not violated.

Summary It is disconcerting to be confronted with a student who has attempted to commit suicide. Many universities react by placing the student on involuntary medical withdrawal without a thought to whether such an action is truly best for the student. Moreover, such

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a decision by the school may be impermissible under the Americans with Disabilities Act and the Rehabilitation Act. If Melanie submits a complaint to the Department of Education Office for Civil Rights (“OCR”), they are likely to find in her favor in the circumstances outlined here. While the Americans with Disabilities Act excludes a person who poses a direct threat from the definition of an “otherwise qualified” individual, the threat must be substantial and likely. It is not enough that a student may hurt themselves in the future. The school must conduct an individualized assessment to determine whether a genuine threat is posed. Here it will not be enough that Melanie did attempt suicide. After all, at the time she was withdrawn from the nursing program, she had received treatment, was on medication, and was receiving counseling. In this case, the OCR would also require the university to amend its grievance procedure and appeals process. Federal regulations require educational programs to incorporate basic due process standards into their grievance procedures, including appeals. Even in an emergency situation, where the school must act immediately, a student must be given written notice of the decision along with an opportunity to be heard on appeal. In cases involving students with disabilities, OCR also requires universities to provide the name and contact information of the DRP to students. Of course, none of these standards were met in our scenario. Melanie was not only withdrawn summarily from school with no opportunity to be heard and present her evidence as to why she should be allowed to return to campus, but she was not informed how to appeal or told who she could contact to discuss the matter. The DRP for the university should have been consulted before the decision was made to involuntarily withdraw Melanie from the nursing program. As the DRP is well informed of the legal requirements under both the ADA and the Rehabilitation Act, they could have helped the university carefully evaluate Melanie’s situation to determine whether she posed a genuine risk of harm to herself or others. The DRP could also have met with Melanie to evaluate her need for the requested accommodation of time and a half for exams. Finally, the DRP could have met with the nursing faculty to discuss their concerns about what could be done to ensure that Melanie could maintain patient safety during clinical placements. This case demonstrates how important it is for a university to have a DRP who is expected to take an active role in working with faculty, administrators, and students, not only to ensure compliance with federal and state disability law but also to facilitate the development of effective resolutions that support faculty in optimizing the participation of students with disabilities.

References and Resources 1. Americans with Disabilities Act (ADA) of 1990, 42 U.S.C.A. § 12101 et. seq. (West 2014). 2. Bagenstos S. Health professions and the law. In: Meeks L, Neal-Boylan L. Disability inclusion: disability as diversity. Switzerland, AG. Springer International; 2020. (Chapter 8). 3. Bazelon Center for Mental Health Law. www.bazelon.org. 4. Campus Mental Health: frequently asked questions. Judge David L.  Bazelon Center for Mental Health Law. July 2017. Available from: http://www.bazelon.org/wp-content/ uploads/2017/08/2017-07-18-campus-mental-health-fact-sheet-FINAL-1.pdf.

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5. Exceptional Nurse. www.exceptionanurse.com. 6. Jain N. Frameworks for disability inclusion. In: Meeks L, Neal-Boylan L. Disability inclusion: disability as diversity. Switzerland, AG. Springer International; 2020. (Chapter 1). 7. Jane Doe v. Samuel Merritt University, 921 F.Supp.2d 958 (N.D. Cal., 2013). 8. Leadership21 Committee. Campus mental health: know your rights. Judge David L. Bazelon Center for Mental Health Law. Updated June 2017. Available from: http://www.bazelon.org/ wp-content/uploads/2017/01/2017-06-28-Revised-YourMind-YourRights-word-final.pdf. 9. Marks B, Ailey S. White paper on inclusion of students with disabilities in nursing educational programs for the California Committee on Employment of People with Disabilities. June 2014. Available from: https://www.researchgate.net/publication/282917801_White_Paper_ on_Inclusion_of_Students_with_Disabilities_in_Nursing_Educational_Programs_for_the_ California_Committee_on_Employment_of_People_with_Disabilities_CCEPD. 10. Marks B, McCulloh K. Success for students and nurses with disabilities. Nurse Educ [Internet]. 2016 Jan/Feb [Cited 2016 Jan/Feb];41(1):9–12. Available from: https://www.ncbi.nlm.nih. gov/pubmed/26402910. https://doi.org/10.1097/NNE.0000000000000212. 11. Meeks L, Bisagno J, Jain N, Herzer K.  Support students with disabilities in medicine and health care programs. Disabil Compliance Higher Ed. 2015; 21(3): 1, 4–5. 12. Mehta L, Meeks L, Lusk MF, Swenor B, Taylor N. Creating a program within a cutlure of inclusion. In: Meeks L, Neal-Boylan L. Disability inclusion: disability as diversity. Switzerland, AG. Springer International; 2020. (Chapter 4). 13. National Organization of Nurses with Disabilities. www.nond.org. 14. National Council of State Boards of Nursing. 15. Neal-Boylan L, Miller M.  Treat me like everyone else: the experience of nurses who had disabilities while in school. Nurse Educ. [Internet]. 2017 Jul/Aug [Date cited 2017 Jul/ Aug];42(4):176–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27922900. https://doi.org/10.1097/NNE.0000000000000348. 16. Neal-Boylan L, Miller M, Bell J. Building academic communities to support nursing students with disabilities: an integrative review. Build Health Acad Commun J. 2018;2(1):60–73. 17. Nurses with Disabilities. Job Accommodation Network. https://askjan.org/topics/Nurses.cfm. 18. R.W. v. Board of Regents of the University System of Georgia, 114 F.Supp.3d 1260 (N.D. Georgia, 2015). 19. Rehabilitation Act of 1973, 29 U.S.C.A. § 701 et. seq. (West 2014). 20. Resolution Letter to National University. U.S.  Department of Education, Office for Civil Rights. OCR Complaint No. 09-99-2014. 23 Mar 2000. 21. Resolution Letter to Spring Arbor University. U.S. Department of Education, Office for Civil Rights. OCR Complaint No. 15-10-2098. 16 Dec 2010. 22. Settlement Agreement between the United States of American and Quinnipiac University. United States Department of Justice. 29 Dec 2014. 23. United States Department of Education, Office for Civil Rights. Laws & Guidance. https:// www2.ed.gov/policy/landing.jhtml?src=pn. 24. Yennard v. Herkimer Boces, 241 F.Supp.3d 346 (N.D. NY, 2017).

The Student with a Chronic Health Condition: Susan Nacht, a Nursing Student with Narcolepsy

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Sharron E. Guillett and Elizabeth Kane

Case History Susan is a nontraditional student who is entering a Bachelor of Science in Nursing program. When in high school, she had some personal and physical struggles but graduated in the top 30% of her class and obtained her certified nursing assistant (CNA) certification. Susan is a conscientious student but has a math learning disability that emerged in elementary school. Additionally, while in high school, she was diagnosed with narcolepsy, depression, and anxiety with panic disorder. Susan had hoped to go to college immediately following high school, but her father was killed in a car accident and Susan was needed at home to help with younger siblings. She thinks this worsened her anxiety and depression. Susan’s siblings are now grown, and she feels the time is right for her to focus on her own dreams of becoming a nurse. She has worked at a local continuing care facility as a CNA for 7 years. The challenges have been greater than anticipated. Although Susan had accommodations for her disabilities in primary and secondary school, she was hoping to avoid using them in college, fearing that she would be regarded or treated differently by her instructors. However, she is often extremely fatigued, sometimes falling asleep in class or while working on assignments. She struggles with long exams, especially those that are administered later in the day. Susan will need to participate in clinicals, but the sites sometimes require traveling long distances which can be dangerous because of the narcolepsy. She is

S. E. Guillett (*) Elizabeth Wade Custer School of Nursing, Shenandoah University, Winchester, VA, USA e-mail: [email protected] E. Kane Academic Enrichment Center, Shenandoah University, Winchester, VA, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_12

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conscientious about self-care, consistently taking her medications, does not smoke or use drugs, and only occasionally indulges in alcohol consumption. The faculty are concerned that Susan will not be able to attend clinicals and that this will impact her ability to apply the concepts learned in class as well as her ability to complete the program within the time allotted.

Perspectives Barriers from the Perspective of the Student I am afraid to tell anyone about my narcolepsy, especially my faculty. I am worried about driving to clinical, that I might get into an accident or that I might not be able to stay awake during clinical. I am concerned that I might miss important content in class and then I will do poorly on exams.

Barriers from the Perspective of the Faculty Faculty are concerned about Susan’s ability to fully participate in classroom activities and group assignments. Faculty are concerned about Susan’s ability to complete coursework within the semester. Students in this state are required to have a minimum of 500 direct care hours, 15% of which can be completed via simulation. Faculty are concerned about Susan’s ability to manage patient care safely at the clinical site, especially on 12-hour shift rotations. Will Susan be able to safely arrive at destinations and arrive on time? Students who arrive more than 15 minutes late are sent home. Faculty are concerned that Susan may have difficulty concentrating and participating in post conference meetings at the clinical site.

 rom the Perspective of the Disability Resource Professional F (DRP) Perspective Faculty are sometimes concerned about students’ abilities as health professionals to meet the demands both physically and psychologically. While a reasonable concern, the learning institution’s responsibility is to allow equal access to education. Susan’s reluctance to disclose and request accommodations puts her at risk for falling behind. Delayed use of accommodations sometimes raises suspicions from faculty about the truthfulness or need for students’ use of accommodations. Students are sometimes initially reluctant to use accommodations to avoid stigma or negative treatment from instructors and peers or because they think they do not need the accommodations. As the work and demands increase, however, they may realize they need to use them to succeed. At times, students will use accommodations in some classes and not in others, which also raises questions from faculty. In the case of students with narcolepsy, medications need to be timed for best results, and by afternoon, students might not be at their best for testing. Clinical schedules sometimes force changes in the times of tests.

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Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

Points of Discussion What Do We Know? Susan has a documented learning disability. Susan has been diagnosed with anxiety, depression, and narcolepsy. Susan has previously been able to meet academic standards in spite of these diagnoses. Susan’s situation was complicated by family responsibilities created by the death of her father. Susan has been managing her health and her present situation successfully but has concerns about her ability to be successful in college, especially with clinical assignments.

What Do We Need to Know? The school of nursing’s technical standards The school of nursing’s policies related to professional behaviors The school of nursing’s policies related to clinical performance What are the clinical requirements of the program? Are there clinical placements near the student’s residence? Can any of the clinical hours be completed using simulation? If so, what percentage? Note: the percentage allowed is determined by the State Board of Nursing [1]. Can lectures be recorded using a software program? Does Susan require the assistance of another person? Are there particular clinical settings that would be better suited for Susan than others? Should the faculty be concerned about Susan’s ability to perform in lab?

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 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? Office of Disability Services Dean/Director of Nursing Program SON Student Handbook SON Director of Student Services Clinical Coordinator Office Office for Information Technology Counseling Center

Discussion Questions 1. Does Susan qualify as a person with a disability who requires accommodations to have full access to your program? Yes. Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the day. The courts have ruled that this condition does limit major life activities and therefore it is covered under the ADA. Susan also has a history of anxiety and depression, conditions which protect her from discrimination under the ADA. 2. If the student wanted to take a leave of absence, what mechanisms are in place to support the student’s exit and reentry to the program? Susan might be allowed a leave of absence but needs to be aware of the possibility that there could be an impact on progression and her completion date. This may affect financial aid and when aid repayments will start. Timing is important. Students typically have a 6-month grace period before they have to start making payments on their loans while they are out of school. Susan would be allowed to get her institutional aid back if she only sits out one semester and does not have any academic problems. She should be advised to sit down with a financial aid representative to be sure she is clear on her status and responsibilities. At some schools, she might only be eligible for school aid and state aid for a total of eight full-time semesters. Since retention and completion rates are important factors in program accreditation, Susan will be followed by her advisor and the student affairs team who will encourage and support her return. 3. What, if any, student affairs or student support resources can be utilized? In addition to formal accommodations, the student can utilize other disability support services, such as student coaching, to address time management, organization, and study skills. Other support services that can be used are those such as

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peer tutoring or the writing center, to strengthen academic skills, as well as the counseling center to address issues with anxiety and depression. These services can also help Susan reduce anxiety related to exams and assignment completion. 4. What financial resources are available to the student? Encourage the student to pursue scholarships that are only open to students with disabilities. Work study or other student employment might help Susan engage in school activities, provide an income, and reinforce skills. Students may rent books at a discounted rate. Faculty and other student support services can assist Susan with finding these and other textbook programs as well as low-­ cost lending programs. 5. How might you leverage Susan’s strengths to mitigate her difficulty during this time? Susan is a motivated and conscientious student with work experience in the field. She might be receptive to utilizing available resources. She should be encouraged to advocate for herself and to meet with the DRP and student services director on a regular basis to make sure her needs are met. 6. How would you approach responding to the faculty concerns regarding this student? The faculty concerns should be acknowledged as legitimate; however, faculty should be reminded that students must not be evaluated based on the “essential functions” of a future nursing job. The top priority for the faculty is to educate the student and move him or her to degree completion. It might be helpful for the faculty to learn more about narcolepsy. Accurate information can be found by contacting the National Narcolepsy Network. What the student does with the education is up to the student. To that end, faculty should advocate for Susan, praising her strengths and providing support. While it is important for faculty to be aware of and follow the policies and standards of the university and the school of nursing, they must recognize that these standards may be met in a variety of ways. In Chap. 10 of the companion text, Moreland and colleagues offer suggestions on ways to manage clinical rotations [2]. Faculty must guard against the prima facie assumption that having a disability makes one unsafe to practice. Policies and standards affecting Susan are outlined in her school of nursing admission documents that refer to technical standards and in the school of nursing handbooks that address professional conduct and clinical practice standards. These documents are discussed in Chap. 10.

Potential Accommodations for Susan It is important to recognize that Susan is the expert on her own health. Each person’s experience with their condition will be unique to their own experience. Susan should select which of the accommodations listed below would be beneficial for her.

122 Didactic course Tests scheduled at a time that works best for the student’s experience of the condition (some testing may be better at certain points in the day) Audio recordings of lectures Copy of professor’s notes per student request Peer notetaker Flexible attendance/tardiness Breaks as needed Preferential seating (to allow easy access for breaks if needed) Testing in a distraction-free location and extended time on tests

S. E. Guillett and E. Kane Lab Skill tests scheduled at a time that works best for student

Simulation Full use of simulation opportunities at a time that works best for the student

Clinical Shift assignments that match student need Clinical assignments as close as possible to avoid driving long distances

Breaks as needed

Guidance from Chap. 9 The use of technical standards is discussed in detail in Chap. 9 of the companion text. It is important to not confuse technical standards required to succeed academically with the essential functions of a nursing job which only apply to employees. Even though the disability literature calls into question the appropriateness of technical standards, many nursing programs use them as criteria for admission and matriculation. Susan’s school has the following standards related to behavioral and mental health: 1. Must possess the emotional health required to exercise good judgment and promptly complete all aspects of the nursing process related to the diagnosis and care of patients and families 2. Must be able to maintain effective relationships with patients, family, peers, faculty, and staff under all circumstances 3. Must have the emotional stability to function effectively under stress and be able to change 4. Must possess the skills necessary for effective relationships in diverse environments Susan needs to determine if there are any areas in which she may need assistance. For example, it would be in her best interest to clarify what “promptly complete” means in standard #1. She may also want to discuss potential “stressors” alluded to in standard #3 and anticipate what her responses might be.

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Professional Conduct Susan’s school also has a policy related to professional behavior and safety that might pose problems for her. It states that among other behaviors, students must: 1. Be on time for all school-related events and activities. 2. Be prepared for class, clinical, and lab. Any concerns that Susan has about her ability to demonstrate these behaviors should be discussed in advance along with any accommodations that could be put in place. The DRP can assist Susan to develop a plan and help her discuss potential difficulties with her clinical instructor.

Clinical Practice Standards The student handbook also states that a student may be sent from the clinical site and/or dismissed from the program for demonstrating any practice that is deemed to jeopardize the health or safety of clients, their families, or other members of the healthcare team. Susan should work with the DRP and her clinical instructor to discuss how to plan the day so that safety is always maintained.

Potential Accommodations for Susan Recognize the student as the expert on their own health. Each person’s experience with their condition will be unique to their own experience. The student should work with the DRP and faculty to select which accommodations will be most helpful to her.

Summary Susan has shown that she is capable of managing her disability and should be commended for her efforts. Faculty should work in concert with the DRP to support Susan in her educational pursuits. Faculty may want to give the student the option of standing during class. This option can be provided to all students as part of class rules at the beginning of the semester so as not to single Susan out or inadvertently disclose her disability. Clinical placements should be selected based on shift start times as well as proximity to the student’s home. Simulation should be used to its full extent to supplement clinical, as appropriate. Adjunct clinical faculty should be

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aware of school policies and disability regulations and how they apply in this situation. The course faculty, clinical faculty, and student should discuss student concerns and how best to address them. Perhaps the student is concerned about periods of inactivity and would be more comfortable staying physically active or working with a buddy initially.

References 1. McKee M, Gay S, Ailey S, Meeks L.  Technical standards. In: Neal L, Meeks L, editors. Disability as diversity: a guidebook for inclusion in medicine, nursing, and the health professions. Cham: Springer Publishing; 2020. (Chapter 9). 2. Moreland J,Fausone M, Cooke J, McCullough C, Hillier M, Clifford G @Meeks L. T. Clinical Accomodations and Simulation In: Meeks L, Neal-Boylan L, editors. Disability inclusion: disability as diversity. Cham: Springer International; 2020. (Chapter 10).

Resources Americans With Disabilities Act of 1990, Pub L. No 101-336. Equal Employment Occupation Comission. Depression, PTSD & other mental health conditions in the workplace: your legal rights EEOC-NVTA-2916-11.2016. (Internet) Available from https:// www.eeoc.gov/eeoc/publications/mental_health.cfm. Narcolepsy network http://narcolepsynetwork.org. National Council of State Boards of Nursing available from www.ncsbn.org.

Part III Focused Topic Cases

The Student Using Medical Marijuana

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Leslie Neal-Boylan and Charlotte H. O’Connor

Case History Adrian is finishing her sophomore year of a baccalaureate nursing program at a large state university. She is very excited about starting the nursing-specific, and especially the clinical, courses. Adrian was recently diagnosed with a chronic illness and finds that marijuana helps ease discomfort. Adrian’s parents are concerned that using marijuana will jeopardize Adrian’s ability to participate in clinical placements and ruin chances of graduating from the nursing program. Adrian decides to send an email to the clinical placement coordinator at the school of nursing. Being proactive might be the best option to avoid being viewed as dishonest. The email describes Adrian’s chronic condition and use of marijuana for pain. It specifically inquires whether this will impact clinical placements and mentions Adrian’s parents’ concern. Adrian’s parents have asked that a medical provider confirm that marijuana is needed for this condition and is better than alternative pain remedies. Adrian mentions that the process of obtaining a medical marijuana card has already begun. The clinical placement coordinator brings the email to the attention of the BSN program director. He involves the dean. This is the first time this situation has arisen in this school of nursing. The dean consults with the associate dean of academic affairs and the assistant dean for student affairs. The deans decide to refer the student to the Office of Disability Services (ODS) on campus. They apprise the disability resource professional (DRP) that this situation has occurred.

L. Neal-Boylan (*) Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA C. H. O’Connor Office of Medical Student Education, University of Michigan Medical School, Ann Arbor, MI, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_13

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Perspectives Barriers from the Perspective of Student I may miss out on good clinical experiences due to marijuana use. I know that patient safety is a priority, but if I do not use marijuana to control pain, my ability to be a good nurse and protect patient safety may be diminished. Receiving accommodations makes me look different to faculty and may affect my grades. Receiving accommodations will cause my peers to see me differently.

Barriers from the Perspective of Nursing Program Federal law states that the use or presence of marijuana is prohibited on campuses. The dean’s office is concerned about patient safety and whether the student will be impaired while taking care of patients. The dean and faculty in the school of nursing perceive an ethical obligation to provide clinical agencies with nursing students who can provide safe care to patients.

 arriers from the Perspective of the Disability Resource B Professional (DRP) Marijuana use is legal in this state. The student should receive the same treatment as any other student with a disability or chronic illness. Marijuana use should be regarded equally to the use of opioids to treat pain. The student’s privacy must be maintained.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

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Points of Discussion What Do We Know? Adrian has a chronic illness that can cause pain and discomfort. Adrian has performed as a very good student to this point. Adrian has been proactive and transparent in revealing the issue and the concern. The nursing program has not experienced an issue like this, and, to its knowledge, neither have their neighboring peer institutions.

What Do We Need to Know? How to work with ODS as a resource What is the role of a legal consultant in decision-making? What other resources might be useful to the student? How much can the deans, faculty, and the clinical placement coordinator reveal to others (and to whom) about this situation? Do all clinical placement sites require drug toxicity screens that include marijuana? Does the nursing program have an ethical/legal obligation to inform clinical placement sites about the student’s marijuana use? Should the school of nursing require all students to sign a statement of understanding and agreement with policies of clinical placement agencies, especially those that govern student expectations and ability to practice if they test positive for any legal or illegal drug?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? University attorney Title IX coordinator Disability support person Professional organizations (e.g., AHEAD) Dean of Students/Student Affairs Student Health Center State Department of Public Health Board of Registered Nursing

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Discussion Questions 1. What is the law in your state? The use of marijuana for medicinal purposes may be legal in the state where the student is attending school. Adrian was proactive in disclosing the illness and use of marijuana for a medical condition. The dean’s office took appropriate action by referring Adrian to the DSO. It is within the purview of the DSO to speak to university attorneys if they need to clarify what applies in a particular state. 2. If you work in a public university, you must uphold federal law. What if you work in a private institution? Federal law prohibits use or presence of marijuana on any college or university campus. See https://www.civilized.life/articles/cannabis-on-campus-adeep-dive-inside-higher-education-pot-policy-in-legal-states/. 3. What are the policies at each of your clinical placement sites? Does your college or university have a policy regarding the use of marijuana in clinical settings? Students are subject to the specific policies of each clinical site to which they are assigned. Many hospitals and other clinical sites require toxicology testing but not for marijuana. Some clinical sites might change a positive result on a toxicology screen to a negative result if the student has a prescription or other medical evidence that he/she needs to take a particular drug. If the school of nursing has a policy to inform all clinical placement sites about all medications each student takes, then the school of nursing should adhere to this policy for all students. The clinical site has the discretion to make a decision based on the information it receives. However, if it is not the school’s policy to provide lists of all student medications to all potential clinical sites, then the school of nursing must not violate the student’s privacy by revealing that this student uses marijuana or any other drug. Similarly, the school shouldn’t inform a clinical site that a particular student has an illness or has not had a particular vaccine required by the site. The school of nursing should be aware of the policies for each clinical site and not send a student to a site with a health requirement that the student does not meet. However, students who report not being vaccinated or that they have an illness should be referred to the DSO on campus. If the school of nursing has a policy of not admitting any student who does not meet certain health requirements, then the school may choose not to admit a student who has not met the health requirements. 4. Would you give a student like Adrian accommodations? What if he is unsafe in the clinical setting? In Adrian’s case, the DSO might choose to grant Adrian an accommodation requiring the clinical placement coordinator only place Adrian in clinical sites that don’t have toxicology screens. However, this requirement can be deemed an “unreasonable accommodation” if the only choices for clinical sites that meet Adrian’s learning needs require toxicology screens. Keep in mind that veteran’s hospitals and public health organizations are also subject to federal law.

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If a student, regardless of the medications they use, exhibits unsafe or impaired behavior, then that situation should be managed according to the policies of the clinical agency and the school of nursing that apply to every student exhibiting these behaviors.

Guidance from Chaps. 2, 4, 8, 9, and 10 Chapter 2 discusses the disparities experienced by individuals with disabilities. In Adrian’s case, the school of nursing (SON) faculty and dean assumed Adrian would jeopardize patient safety and that allowing this student to attend clinical would cause their school to be viewed as unethical. This unfairly targets Adrian and assumes she will not practice safely before giving her a chance to practice. Chapter 4 discusses a culture of inclusion and reminds us that a team approach is required to analyze complex cases that might require accommodation. Chapter 8 discusses the law and reminds faculty and administrators that the law and not hearsay, assumptions, or preferences must guide difficult decisions. The Americans with Disabilities Act (1990) and its amendment (Americans with Disabilities Act Amendment Act, 2008) are threaded throughout the book. Chapter 9 is relevant to Adrian’s case because the technical standards we develop for nursing programs must align with the ADA and be compliant with its statutes. Schools of nursing should apply academic technical standards, not the essential functions of nursing jobs to the expectations for students. Chapter 10 discusses clinical accommodations and modifications. It is relevant because we must scrutinize each agency’s policies and requirements. Adrian could be sent to a clinical placement site that does not require marijuana testing. Her use of marijuana would not be mentioned unless the school of nursing has a policy stipulating that a list of all medications all students use is sent to the clinical sites in which each student is placed. If the student displays unsafe behavior in clinical, then the school’s policy regarding unsafe practice in clinical should be applied as it would be for any nursing student who is unsafe for any reason, in the clinical setting.

Summary A case such as Adrian’s is likely to become more common for all healthcare professionals and health sciences students. It is important be proactive and look at your institution’s policies with a plan to develop a policy if none exists. Your ODS may not have encountered this situation yet. Everyone will need the guidance of the institutional attorneys to be sure you are compliant with state and federal law. Don’t make assumptions because this involves a recreational drug and one that was previously illegal.

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References and Resources 1. Americans with Disabilities Amendments Act (ADAAA) of 2008, Pub. L. No. 110–325, 122 Stat. 3553 (2008). 2. Americans with Disabilities Act (ADA) of 1990, 42 U.S.C.A. § 12101 et seq. (West 2014). 3. Grinspoon P.  Harvard Health Publishing blog [Internet]. Harvard Health Publishing. June 25, 2019. Medical Marijuana. Available from: https://www.health.harvard.edu/blog/ medical-marijuana-2018011513085. 4. Herzog S, Shanahan M, Grimison P, Tran A, Wong N, et al. Systematic review of the costs and benefits of prescribed cannabis-based medicines for the management of chronic illness: lessons from multiple sclerosis. PharmacoEconomics. 2018;36(1):67–78. https://doi.org/10.1007/ s40273-017-0565-6. 5. Wisk LE, Weitzman ER.  Substance use patterns through early adulthood results for youth with and without chronic illness. Am J Prev Med. 2016;51(1):33–45. https://doi.org/10.1016/j. amepre.2016.01.029. 6. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456–73. https://doi.org/10.1001/jama.2015.6358.

The Student Who Brings an Animal to Class

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Patricia Lussier-Duynstee, Christine Low, Elisa P. Laird, and Leslie Neal-Boylan

Case History Tom Burkess is in the second year of a nurse practitioner program. He has done well in the program, but does not readily connect socially with his peers. His clinical seminar consists of ten students and is led by a faculty member. This is the only course for which Tom comes onto campus, as his other courses are either online or are clinical courses. Tom comes to the first seminar class with a medium size dog that is wearing a harness with the word “Volunteer” on it. Tom introduces the dog as Winnie and says that he brings the dog to the local hospital twice a week and visits patients on the in-patient units. He says that having her with him in class makes him feel more comfortable and that unless he is in a clinical setting as a student, he brings the dog everywhere. The dog is a mixed breed resembling a malamute and is a solid white color. Tom’s classmates are very excited about the dog and tell stories of their own pets. Winnie is well behaved, readily following voice commands from Tom, and happily allows Tom’s classmates to pet her. When Tom sits down, she sits alongside him and then lays on the floor on command. The seminar instructor comes into the classroom and is excited to see and pet the dog. She goes over to meet Winnie and learns from Tom that she is a pet volunteer.

P. Lussier-Duynstee (*) MGH Institute of Health Professions, Boston, MA, USA e-mail: [email protected] C. Low Icahn School of Medicine at Mount Sinai, New York, NY, USA E. P. Laird Disability Resource Center, Samuel Merritt University, Oakland, CA, USA L. Neal-Boylan Mansfield Kaseman Health Clinic, Chevy Chase, Rockville, MD, USA © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_14

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The faculty appreciates that Winnie is well behaved and quiet. Tom continues to bring Winnie to school for his seminar. Weeks later, the instructor mentions to the Assistant Dean that her class has a mascot. She describes Winnie and her attendance in class. The Assistant Dean reminds her that there is a no pets policy in university buildings and asks if this is a service dog. The faculty answers that she thinks so, describing Winnie’s work at the hospital with patients, and that Tom said that he feels more comfortable with the dog around. The Assistant Dean asks if the dog performs a service for the student, but the faculty is unable to answer. The Assistant Dean contacts Tom and asks if the dog is a service animal and what service the animal performs. Tom responds quickly and explains that the dog is not “technically” a service animal but makes him feel comfortable in class, is a volunteer, is used to being around people, and is well behaved. He goes on to say, “Winnie is a big part of my life. I like having her with me. She’s my best friend. She is comforting and good company.” He also adds that since he frequently does hospital visits right after class, where Winnie serves as a volunteer therapy dog for patients, it is convenient to already have Winnie with him so he can go straight there. The Assistant Dean tells him that unless Winnie is a service dog, he cannot have the animal in the classroom. Tom says he thinks he should be able to have Winnie in class, even though she isn’t a service animal, but he isn’t able to provide a specific reason, other than that no one objected to having her there. It is evident to the Assistant Dean that there is confusion surrounding what qualifies an animal as a service animal. He knows that a therapy animal is one that is brought into a setting with patients or students or even at airports, to provide people there with a short visit with a dog as a comfort. So Winnie’s work as a therapy animal at the hospital later in the day has no bearing on whether she should be permitted in class, even for Tom’s scheduling convenience. But the Assistant Dean is less certain about whether Tom’s expressions that Winnie makes him feel more comfortable might be a reason she should be permitted to stay. He seeks out consultation from the Office of Disability Services (ODS). The disability resource professional (DRP) explains that in addition to service animals, which are expressly permitted by the Americans with Disabilities Act (ADA), there is another type of animal that can be permitted in educational environments in some circumstances. The DRP describes emotional support animals (ESAs), which she says, when needed for a disability-related reason, should be permitted in places where pets are not allowed when necessary as a disability accommodation. The DRP cites an Office for Civil Rights (OCR) case, Pennsylvania State University, No. 03-18-2103 (2018), and says the OCR told the school that to determine whether an ESA should be allowed to accompany a student into educational environments, they must engage in the interactive process as would happen with any other kind of request for accommodation. The Assistant Dean realizes that it is necessary in this case to refer the student to the ODS to verify a disability and determine if an accommodation is appropriate. He notifies Tom that he should contact the ODS to discuss whether Winnie may be an ESA and should not bring Winnie to class until he has completed the ODS interactive process.

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Perspectives Barriers from the Perspective of Student I take Winnie to the hospital to visit patients each week after class, and it is easier for me if Winnie can just come with me in the morning and we then go to the hospital. My classmates also like having Winnie in class – so what’s the big deal?

Barriers from the Perspective of Nursing Program Tom does not have evidence that Winnie is a service animal; in fact, he does not claim that she is more than a volunteer and a comfort. Winnie does not meet the criteria of a service animal. The student has not gone through the interactive process with the ODS, so it isn’t clear if Winnie is an ESA. The school has a “no pets” policy in campus buildings. The school’s policy on animals is unclear. The school allows service animals, as it must be under the ADA. However, not everyone is aware that emotional support animals may be required in certain circumstances.

From the Disability Resource Professional (DRP) Perspective The ADA defines what constitutes a service animal (http://www.ada.gov/service_animals_2010. htm). A service animal must provide a distinct service to the student and, if so, must be permitted in most educational environments. They are limited to either dogs or miniature horses. Tom has already been asked the two relevant and legally appropriate questions: “Is the animal a service animal?” and “What service does the animal perform?” Tom indicated that Winnie is not a service animal, so it is appropriate for Tom to be informed the animal cannot come to class unless the ODS confirms this is a disability accommodation. The ODS should confidentially discuss with Tom whether he has a disability and whether Winnie may be an appropriate accommodation. Tom needs to show that Winnie’s presence allows him to have equal access to the class and, without her there, he would not be able to attend and/or participate. If Tom had answered that the animal is a service animal and defined the service, there is no required proof he can be asked to provide, as it is illegal under the ADA to require documentation for a service animal.

Deconstructing the Barriers and Access Issues Use the following questions to guide the process of deconstructing the case and determining reasonable accommodations.

Starting the Process What do you know? What do you need to know? How and where might you access new information that may lead to enhanced access?

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Points of Discussion What Do We Know? Tom is bringing his dog, Winnie, to class each week. There is a no pets policy, and it is unclear whether Tom’s dog is a service animal or an emotional support animal, which would remove them from the no pets policy. To be a service animal, there are two questions that can be asked: “Is this a service animal?” and “What task(s) is this animal trained to perform?” The person with a disability cannot be asked to show proof of training, and the dog does not need to wear any identifying vest or tag. To bring an emotional support animal into educational spaces such as the classroom, Tom must be an individual with a disability for which the animal is an accommodation that ameliorates a disability-related barrier. Tom does not claim that Winnie is a service animal but would like for his dog to be allowed to stay in the classroom.

What Do We Need to Know? What defines a service animal? What is the distinction between service animals, emotional support animals, therapy animals, and pets? Does Tom have a disability? If so, has he engaged with the ODS regarding whether Winnie can accompany him to class as an emotional support animal? Is Winnie’s presence in the classroom necessary for Tom to be able to attend or participate in class?

 here Can the Disability Resource Professional Find the Information W Needed to Help Determine Reasonable Accommodations and Support for This Student? The Americans with Disabilities Act (1990) Section 504 of the Rehabilitation Act The Office of Disability Services OCR Letter to Pennsylvania State University, Case No. 03-18-2103 (2018) DOJ’s Service Animal Guidance Nursing Faculty, Assistant Dean, and Dean

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Key Points from This Case

• Institutions should have clear policies about pets, service animals, and emotional support animals. • The ADA defines what constitutes a service animal (https://www.ada.gov/ regs2010/service_animal_qa.html). • Only two questions are legally permitted: “Is the animal a service animal?” and “What service does the animal perform?” • If a student says the animal is a service animal and defines the service, he/ she cannot be asked to provide proof, as it is illegal under the ADA to require documentation for a service animal. • To bring an emotional support animal into educational spaces such as the classroom, the individual with a disability must show the animal is an accommodation that ameliorates a disability-related barrier. • Other’s allergies or animal fears are not valid reasons for refusing the use of a service animal or emotional support animal.

Discussion Questions 1. Does your institution have a clear, written policy about animals on campus? Does it make the distinction between service animals, emotional support animals, and pets? Does the policy contain clear information on the two questions that can be asked regarding service animals and information about where to refer students or employees who would like to seek an emotional support animal as a disability accommodation? It is important that institutions have clearly written policies to avoid confusion. The school of nursing should comply with the institution’s policy; however, the school of nursing may need to create an addendum that addresses clinical placements. If a student has an accommodation for an animal, it is important to work closely with the clinical site to find out their policies regarding service animals and emotional support animals. The US Centers for Disease Control and Prevention (CDC) has stated in its manual, Guidelines for Environmental Infection Control in Health-Care Facilities, that service animals should be permitted in most places in a healthcare facility where personal protective equipment (PPE) is not required (CDC, 2019, n.p.). According to the CDC, if humans must wear masks and gowns for infection control, then animals should not be permitted to enter. However, not all healthcare settings are aware of this, so close work with the site is important to ensure a student who relies on a service animal is able to have that animal in clinical spaces. ESAs should be evaluated as an accommodation in that space. If humans can enter without PPE, then service animals can enter unrestricted.

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In the event that no clinical partners will allow an animal on the premises for a specific placement (e.g., an ICU rotation), faculty could unbundle the clinical learning objectives associated with that placement and design ways for the student to meet those objectives through varied assignments, including simulation. Ultimately, the school is responsible for ensuring the student’s ADA rights are upheld. 2. Are your colleagues (faculty and staff) knowledgeable about policy regarding service and emotional support animals, including what questions they legally can and cannot ask? Faculty and administrators need to know the difference between service and emotional support animals to be able to guide students who come to campus with an animal or who request to do so. Service animals are presumed to be permitted in educational spaces, much as a wheelchair or cane might be, which is why only the two questions are permitted under the ADA. A school cannot legally have a process to “clear” or “approve” a service animal in educational settings, nor can it ask about the nature or extent of the individual’s disability. The ADA defines a service animal as a dog or, in some circumstances, a miniature horse. The dog must be trained to do a task for the person, but the school is legally forbidden to ask for a demonstration of the training, paperwork, or other “proof” that the dog is trained to do a task. Emotional support animals are a disability accommodation, like extended time on testing or a seat at the front of the classroom. A student may receive an accommodation to have an ESA in class if the student has a documented disability and there is a clear nexus between the disability-related barrier and the presence of the animal. For example, students with an anxiety disorder who struggle to be able to get to class and be attentive may find that having a dog on their laps or at their feet provides an anchor that allows them to attend. Note that ESAs are not limited to dogs – they may be many types of animals. The primary difference between an ESA and a service animal is the training: ESAs are not trained to do anything; it is their mere presence that supplies the therapeutic benefit. The two questions permitted by the ADA (“Is this a service animal?” and “What is it trained to do?”) are designed to allow entities to be able to distinguish service animals from ESAs. Note: the laws that apply to housing are very different from those that apply to the classroom. The situation of students with any type of animal who live in campus housing should be analyzed under the standards of the Fair Housing Act. 3. Do your faculty attend annual professional development on topics of accommodations, including the use of service animals?

Potential Accommodations for Tom In this case, the only accommodation at issue is whether or not Winnie is a service animal, ESA, or a pet, and it focuses only on the classroom environment – not clinical or housing spaces.

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Guidance from Chaps. 8 and 9 Chapter 8 describes the law as it applies to the health professions and health science programs. While the chapter doesn’t specifically discuss the law as it applies to service animals or ESAs, it provides a comprehensive discussion about the legal foundations for supporting people with disabilities.

Summary The law makes a clear distinction between pets and service and therapy animals. It is important that the institution, faculty, and staff are careful to only ask the questions permitted by law unless or until it is established that the animal is not a service animal. For non-service animals, further questions may be asked to ascertain whether the student should be referred to the disability office to engage in the interactive process to determine if the animal is an ESA or counseled about the no pets policy. Allowing any student to bring in a pet decreases the importance of permitting students to be accompanied by a qualifying animal. Further it may cause problems as not all therapy animals or pets will be well controlled and well behaved. It is important to note that others’ allergies or fears do not provide legitimate cause for the denial of the use of a service animal. In these instances, the student with the allergy or fear of the animal should be evaluated for an accommodation which may include assignment to a different room or building from the service animal. If the handler cannot control the animal or the animal is not housebroken, only then can the person with a disability be asked to remove the animal from the premises. If that happens, the person with the disability must be offered another way by which they can access services without the presence of the animal. This would also apply to the use of ESAs. There should be clear, written policies that define ESAs as a reasonable accommodation and establish the referral process for seeking the accommodation. Faculty should receive updated annual training regarding compliance with the ADA, including the animal policy. A pamphlet outlining the school’s policies for all types of animals (pets, therapy animals, ESAs, and service animals) would be helpful to students and faculty.

References and Resources 1. 2. 3. 4.

Americans with Disabilities Act regulations, 28 CFR § 35.136. Fair Housing Act, 42 U.S.C.A. 3601, et seq. OCR Letter to Pennsylvania State University, Case No. 03-18-2103 (2018). U.S. Department of Health and Human Services, Center for Disease Control and Prevention. (Last updated: 2019 July.) Guidelines for Environmental Infection Control in Health-Care Facilities. Atlanta: Center for Disease Control and Prevention. p.  123–4. Retrieved from: https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf 5. U.S. Department of Justice, Civil Rights Division, Disability Rights Section. (Last updated 2020, February 24). Service Animals. Retrieved from: https://www.ada.gov/service_animals_2010.htm

The Student Who Fails the Medical Board Exam

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Kristina H. Petersen and Lisa M. Meeks

Case History Miguel grew up in the Bronx, NY, and was accustomed to working hard for everything he achieved. He developed his work ethic from his mom, a single mother who worked 6 days a week as a home healthcare aide. Miguel applied his strong work ethic to his schooling and earned a full scholarship to Lehman College. He commuted from home and maintained a 3.5 GPA in biomedical engineering while also taking care of his siblings. Miguel participated in a pathway to medicine program for underrepresented students that paired him with a physician mentor and offered tutoring for the medical school entry exams. Miguel struggled with the medical school entry exam, scoring in the borderline range for admissions. He worked with a tutor two to three times a week, and on his second try, he improved his entry exam score to the minimum range for admissions to his top choice school, a small medical school with a focus on serving underrepresented populations who intend to enter primary care. When Miguel matriculated to medical school, he was very nervous and felt out of place; he eventually became homesick. His peers seemed to intuitively understand “medicine,” and many of them had parents who were physicians. In contrast, Miguel seemed to struggle from day 1. Attending medical school was like learning a new language while also learning a large amount of science. He quickly identified with the phrase that equates learning in medical school to “drinking water from a fire hose.” Miguel failed his first exam and met with the campus learning specialist K. H. Petersen (*) New York Medical College, Valhalla, NY, USA e-mail: [email protected] L. M. Meeks Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA e-mail: [email protected] © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4_15

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(LS) to discuss a study plan. After applying more active approaches to studying, and creating a weekly schedule to help him stay on task and manage his time more effectively, Miguel’s scores improved. Although he was passing, his scores were far below the class mean and Miguel continually ran out of time on his exams. For the remainder of the first and second year, Miguel struggled, but with the consistent help of a peer tutor, he maintained passing scores. While preparing for his Board exams, however, Miguel found himself earning non-passing scores on practice exams, leaving at least 25% of the questions unanswered. Miguel was again referred to the LS, who inquired about Miguel’s educational past and whether “time” had ever been an issue. Miguel recalled that during secondary school he had been on an individualized education plan (IEP) but that at some point the IEP was removed due to his strong academic performance. The LS recommended Miguel meet with the disabilities office to discuss his history in more detail and to determine whether a testing accommodation may be warranted. Miguel resisted a meeting, scared by the implication that he may have a disability and already feeling like he did not fit in. Although Miguel continued to meet with peer tutors, he stopped meeting with the LS and instead focused on working harder – as he always had – to improve his performance. After failing the next course exam, Miguel became frustrated because he felt he was working harder than ever and for the first time feared he might not make it through medical school. Given his exam failure, Miguel was required to meet with the Student Affairs (SA) Dean. When asked about his approach to studying, Miguel recalled his meetings with the LS and her referral to the disability office. The SA Dean, having worked with multiple students who received accommodations, encouraged Miguel to follow through with the referral and noted that accommodations are not retroactive. Miguel met with the disablity office and  was assigned a specific disability resource professional (DRP). She informed Miguel that in order to get testing accommodations he would require a current neuropsychological evaluation. When  Miguel found out how much the evaluation cost, he was shocked. Where would he get several thousand dollars? Miguel was frustrated to learn that if he wanted to get accommodations on his Board exams, he would also have to provide a full history of accommodations and recount his struggles in a personal statement. The DRP worked with Miguel to increase his financial aid eligibility so he could take out loans to cover the cost of the assessment and helped him locate a neuropsychologist who could complete the testing with a short turnaround time. Following the evaluation, Miguel was diagnosed with ADHD. He was prescribed medication and given suggestions for approaches to studying and recommendations for accommodations – including extra exam time. The disability office subsequently granted him time and a half on written exams in a smaller room to minimize distractions. Immediately, Miguel felt a weight had been lifted from his shoulders; with the extra time and the quiet room, Miguel’s course exam performance increased significantly. Finally, Miguel was getting positive results from his hard work!

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The DRP told Miguel that the Board requirements are stringent and recent diagnoses (especially ADHD) have a slimmer chance of being approved; she suggested he pour all of his efforts into exam preparation instead of wasting his energy compiling an application for accommodations on the Board exam. A friend also told him that students with accommodations get flagged and that residency programs would know if he had accommodations. Miguel, certain the DRP and his friend were right, did not apply for accommodations. Miguel took the Board exam without accommodations and failed by two points. After his score was released, he was abruptly pulled from clinical rotations. In keeping with school policy, Miguel was informed he could only take the exam two more times and was not allowed to continue clinical curriculum until he received a passing score. He was told to begin studying for the Board exam again. The SA Dean recommended he apply for accommodations. She dismissed the claim that scores are flagged, showing Miguel a statement on the Board website that specifically denounces the practice of flagging. She was irritated with the DRP and told Miguel that many medical students have had success with applications for accommodations on Board exams and that, while labor intensive, he should not be discouraged from applying. Miguel felt like he wasted a test administration and recognized that residency programs will see his first failure, making the match process even tougher. Due to the long application process associated with seeking Board accommodations, Miguel was forced to take a leave of absence (LOA). During his LOA, he moved back home with his mom and worked part-time to pay for living expenses and health insurance that he’d lost as a result of his leave. He was also restricted from using any university resources like the learning center, the library, and counseling services. Miguel was resolved to use this time to obtain accommodations on the Board exam, certain that he would easily pass with the extra time he so desperately needed. He tried to study, compiled and submitted his accommodation application, and awaited a decision that took 120 days. His application was ultimately denied, partly due to what the Board deemed as a “lack of history of impairment and accommodation.” With only a few months left in his LOA, Miguel was forced to take the Board exam without accommodations if he had any hope of returning to school. He took the exam for the second time without accommodations and failed by one point. Miguel is understandably devastated and does not know what to do. His anxiety skyrocketed as he now faces the institution’s “three strikes” policy, which states that if a student fails the Board exam three times, they are dismissed. Miguel has a meeting next week with the SA Dean who is also concerned and wonders how she and her team can support this student. She is encouraged by the complete turnaround in Miguel’s in-house exam performance after implementing institutional accommodations and is certain that he will make an excellent physician. She is also concerned about the disproportionate impact on Board exam requirements for students from socioeconomically disadvantaged backgrounds. She wonders  about next steps and how her team can support this student.

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Perspectives Barriers from the Perspective of the Student Concern about not being able to get approved for Board accommodations, including the long wait time once the application has been submitted to receive a decision The need to take a LOA, which presents significant financial barriers (e.g., health insurance, housing, no access to campus support resources) Frustration over receiving contradictory advice from the DRP and SA Dean Dismay that no one from the medical school coached him on how to complete the application for accommodations Fear of dismissal as he faces the school’s “three strikes” policy, which increases his anxiety around passing the exam Wondering if he is really “good enough” to be a doctor The need to take a year’s leave of absence and the distance from his initial cohort Needing to explain the time away from school and his Board exam failures in his residency application

Barriers from the Perspective of the Medical School Students need to demonstrate proficiency on Board exams to graduate If the student can’t pass Board exams, how will he pass licensing exams? If the student can’t demonstrate proficiency on exams, is he qualified to safely treat patients? Can we modify our policies to keep the student enrolled and financially protected and covered under medical insurance? Can we modify policies surrounding access to campus support services while on LOA for this student and future students in similar circumstances? Can we modify the “three strikes” rule, especially given the poor advising the student received from the DRP?

Barriers from the Perspective of the Disability Office The current discrepancy between the application processes for institutional vs. Board exam accommodations The large number of students for a part-time DRP to manage, when the recommended case load is 1:85 Lack of training in best practices around Board exam accommodation application support Difficulty joining national organizations and/or attending meetings that would help educate the DRP on Board exams, due to budgetary constraints Feelings of guilt about suggesting the student not apply for accommodations The denial letter from the Board suggesting that if ADHD was not diagnosed in childhood, a student cannot have a disability Lack of knowledge about ADHD, diagnosing and psychometrics in general, leading to feelings of inadequacy and uncertainty about how to assist the student in appealing the denial

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Deconstructing the Barriers and Access Issues Starting the Process What do you know? What do you need to know? Where might you find new information that leads to enhanced access?

What Do We Know? Miguel is from a single-parent household and participated in supporting his siblings. He received a full scholarship to Lehman College and graduated with a 3.5 GPA in biomedical engineering. He took the medical entry exam twice, scoring just well enough to gain entry through a pathway program for underrepresented students. Miguel experienced academic difficulty immediately upon matriculating at medical school. He was diagnosed with ADHD after a neuropsychological evaluation during his second year in medical school. He had to take out a loan to pay for the neuropsychological exam. He was approved for institutional accommodations: time and a half on exams in a smaller room to minimize distractions which immediately improved his exam performance. The DRP initially discouraged Miguel from applying for Board exam accommodations. Misinformation from Miguel’s friend led him to believe that the Board may “flag” students who take Board exams with accommodations. After failing the Board exam by two points, the SA Dean pulled Miguel from his rotations and recommended he apply for accommodations, which necessitated him taking a LOA. Miguel applied for Board exam accommodations while on LOA and was denied. He took the Board exam a second time and failed by one point. Miguel is facing the school’s “three strikes” policy, so he feels increased anxiety and pressure to pass.

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What Do We Need to Know? What are the requirements for obtaining Board exam accommodations? What documentation was included in Miguel’s application for accommodations? Is there any way he can improve his chances with additional documentation? Can someone from the disabilities office coach students like Miguel to complete applications for Board Exam accommodations? What is the appeal process for the Board exam? What academic, financial, and emotional support can the institution offer to a student in this position?

Where Might You Locate Information that Leads to Enhanced Access? Institution’s Policy on Accommodations & Accessibility Application and appeal requirements for Board exam accommodations US Department of Justice Recent OCR decisions on institutional exam accommodations Recent case law on Board exam accommodations Jain NR, Meeks LM.  The Process of Requesting Accommodations on Certification, Licensing, and Board Exams: Assisting Students Through the Application. In Meeks LM, Jain NR, Laird E, editors. Equal Access: The Guide to Assisting Students with Disabilities in Health Science and Professional Education, 2nd Edition. New  York: Springer Publishing Company; 2020. UCSF School of Medicine USMLE Step Exam Guide http://www.ahead-archive.org/conf/2017%20Conference/Handouts/7.2/ UCSF-USMLEpacketforstepexams.pdf

Discussion Questions 1. How can the institution work proactively to ensure that students receive accurate information regarding Board exam requirements? It is critical for the institution to distribute information about applications for institutional accommodations as early as possible, ideally at matriculation. DRPs should discuss accommodations with all students as soon as they arrive on campus to ensure all students are aware of the Board’s process for accommodation requests and can begin the process early. By engaging the students in conversation about this process early, misinformation can be avoided, allowing students to make decisions based on accurate and

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timely information. Unfortunately, misinformation is rampant surrounding the “flagging” of scores, in part because this practice only ended fairly recently, and many advisors and students have not yet received the most current information. 2. What types of documentation best support Miguel’s diagnosis of ADHD? What might he want to address in a personal statement within an appeal? Miguel’s neuropsychological report is important, as it provides the results of specific tests that led to his diagnosis of ADHD. In addition, Miguel could include a letter from his treating psychiatrist who is monitoring his treatment and prescribing medications. All letters from treating clinicians should be written in as much detail as possible. Contrary to the types of letters physicians are accustomed to writing that by design usually contain as few details as possible to protect patient privacy, the Board requires detailed information about the rationale for the diagnosis based on tests that were performed and data that were collected. Clinicians should also focus on the functional limitations that result from the student’s diagnosis and how those limitations hinder the student’s major life activities (as defined by the ADAAA of 2008) and how the disability specifically impacts the student’s ability to access this exam. If Miguel has copies of his previous IEP from elementary school or previous report cards/evaluations that specify symptoms of what would later be diagnosed as ADHD, this could be supportive of his history with these symptoms even though they were only recently labeled as ADHD. Within his personal statement, he should make clear what types of support he received at home or at school during the entirety of his educational experience in order to succeed academically. For example, if Miguel regularly attended a community after-school homework support program and/or worked with professors during office hours and/or worked weekly with a peer tutor, all that should be specified in his personal statement. Miguel should try to include any supporting documentation he has that his ADHD symptoms, although diagnosed only recently, have impacted him in various aspects of his life (home, work, school) for many years. Miguel should not suggest he has overcome his disability but rather he has been able to compensate for years prior to entering medical school. 3. Is it possible for a student with a recent ADHD or learning disability diagnosis to get approved for Board exam accommodations? Yes, students with recent ADHD and learning disability diagnoses are covered by the ADAAA of 2008 and have been granted accommodations by Board entities. It is critical to support these cases with detailed letters from clinicians, a full neuropsychological report, a detailed student personal statement, and any additional documentation warranted in each specific case. 4. What other types of documentation can support a student in Miguel’s’ position? Documentation may include detailed letters from clinicians, a full neuropsychological report, any past report cards or IEP or work evaluations that indicate the student was experiencing symptoms prior to the diagnosis, a detailed personal statement, any other documentation specific to the student’s case, and an institutional letter of support from the DRP.  The DRP’s letter of support should

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highlight key points from all the documentation, supporting the student’s requirements for accommodations with recent case law and appropriate citations of Section 504 of the Rehabilitation Act and the ADA/ADAAA of 2008, and speak to the considerable improvement in performance once accommodated. 5. What kind of support can be provided by the DRP to assist students in preparing their Board accommodation applications? • Instruct students to start the application process as early as possible to give appropriate time to collect supporting data and allow for an appeal, if needed. A checklist/timeline can be created and given to students about 1 year before they are scheduled to take Step 1 [see the Coalition for Disability Access in Health Science Education website for a reference template: hsmcoalition.org]. • Instruct students to complete applications that are objective-driven with appropriate supporting data provided by treating physician(s) or practitioner(s). • The DRP should work in tandem with the medical professionals, student, and other care providers to ensure all statements are consistent and comprehensive and do not suggest the student “overcame” their disability. While uncomfortable for some, this is the time to highlight the impairment and how this student is impaired on a multiple hour-long, computer-based multiple-­ choice test with long question stems. • The DRP should review student personal statements and provide feedback. • The DRP should ensure the medical school’s letter of support includes a detailed description of the student’s functional impairment(s) and resulting limitations of major life activities, as defined by the ADAAA of 2008. • Ensure the data collected by medical professionals are quoted and/or referenced in the school’s letter of support and the student’s personal statement. 6. What needs to be addressed in faculty letters of support that are submitted with an application for Board exam accommodations? A faculty member’s letter of support should be individualized to each student and include a detailed description of the disability-related barriers the student faced while engaged in educational activities with the faculty member. Although it is more common for faculty to write letters that focus on student strengths, these letters will best support the objective if they focus on the barriers the student has encountered and the consequences of those barriers. Faculty members may need to hear this critical message a few times to understand how these letters differ from those they are used to writing. It will also be prudent to have the student submit a request for the letter in writing, releasing the faculty member from any privacy regulations, giving them explicit permission to write the letter and discuss their disability. 7. What needs to be addressed in a disability office letter of support that is submitted with an application for Board exam accommodations? The disability office letter of support should be individualized to each student and include a detailed description of the student’s functional impairment(s) and resulting limitations of major life activities, as defined by the ADAAA of 2008.

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Letters should highlight the most relevant data collected by medical professionals and parts of the student’s personal statement. Finally, the letter should support the student’s argument that he/she requires accommodations to fully access this specific exam by citing and/or quoting relevant case law and parts of Section 504 of the Rehabilitation Act and the ADA/ADAAA of 2008. Schools are also asked to speak to why they approved accommodations in their educational settings. The Board requirements are very clear that a diagnosis alone is not evidence of impairment. There should be a well-thought-out reasoning behind these decisions, not just “they have [insert Dx].” 8. How is an appeal different from the initial application for accommodations? Specifically, what needs to be addressed and what additional documentation should be provided? It is critical to review the Board accommodation denial letter sentence by sentence and determine what additional documentation can fill the gap(s) the Board identified as the basis for the denial. An appeal should be strongly considered if additional documentation can be provided to counter the arguments and/or if case law exists that supports the current documentation. In the institutional letter of support for the appeal, it is important to focus on evidence-based information to support the student’s case, responding specifically to each argument within the rejection letter.

Resources Berger v. Nat’l Bd. of Med. Examiner Case No. 1:19-cv-99 (S.D. Ohio Aug. 27, 2019). Chapter 13 from the companion book: disability as diversity: a guidebook for inclusion in medicine, nursing, and the health professions. Springer Nature. September 2020. Jain NR, Lewis C, Meeks LM. The process of requesting accommodations on certification, licensing, and board exams: assisting students through the application. In: Meeks LM, Jain NR, editors. The guide to assisting students with disabilities: equal access in health science and professional education. 1st ed. New York: Springer Publishing Company; 2015. Jain NR, Meeks LM. Supporting your students’ request for accommodations on high stakes exams [webinar]. Washington, DC: Association of American Medical Colleges; 2016 [Cited June 6, 2020]. Available from: https://www.aamc.org/professional-development/affinity-groups/gsa/ webinars/supporting-accomodations-requests. Jain NR, Meeks LM. The process of requesting accommodations on certification, licensing, and board exams: assisting students through the application. In: Meeks LM, Jain NR, Laird E, editors. Equal access: the guide to assisting students with disabilities in health science and professional education. 2nd ed. New York: Springer Publishing Company; 2020. Meeks LM.  UCSF School of Medicine USMLE Step Exam Guide. AHEAD 2017 Annual Conference Archive, 2017. [Cited June 6, 2020]. Available from: http://www.ahead-archive. org/conf/2017%20Conference/Handouts/7.2/UCSF-USMLEpacketforstepexams.pdf. Ramsay v. Nat’l Bd. of Med. Examiners, CIVIL ACTION NO. 19-CV-2002 (E.D.  Pa. Dec. 30, 2019). U.S. Department of Justice, Civil Rights Division, Disability Rights Section. ADA Requirements: testing accommodations. 2014. [Cited June 6, 2020]. Available from: https://www.ada.gov/ regs2014/testing_accommodations.pdf.

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United States Department of Justice, Office of Public Affairs. Press Release, February 22, 2011: Justice Department Settles with National Board of Medical Examiners over refusal to provide testing accommodations to Yale medical student. [Cited June 6, 2020]. Available from: https://www.justice.gov/opa/pr/ justice-department-settles-national-board-medical-examiners-over-refusal-provide-testing.

Board Exam Websites for Medical Education National Board of Osteopathic Medical Examiners. 2019. [Cited June 6, 2020]. COMLEX-USA bulletin of information 2019–2020. Available from https://www.nbome.org/exams-assessments/ comlex-usa/bulletin/administration/. United States Medical Licensing Examination (USMLE). 2019a. [Cited June 6, 2020]. Test accommodations: overview and instructions. Available from: https://www.usmle.org/test-accommodations/requesting-accommodations.html. United States Medical Licensing Examination (USMLE). 2019b. [Cited June 6, 2020]. Test accommodations: guidelines. Available from: https://www.usmle.org/test-accommodations/ guidelines.html. United States Medical Licensing Examination (USMLE). 2019c. [Cited June 6, 2020]. Test accommodations: forms. Available from: https://www.usmle.org/test-accommodations/forms.html.

Additional Readings California Board of Registered Nursing. Candidates with disabilities—request for accommodations. 2019a, January. [Cited June 6, 2020]. Available from: https://www.rn.ca.gov/pdfs/applicants/disable.pdf. California Board of Registered Nursing. Request for reapply/repeat examination. 2019b, January. [Cited June 6, 2020]. Available from: https://www.rn.ca.gov/pdfs/applicants/reapply.pdf. Congressional Research Service Report for Congress. Tests and Testing Accommodations Under the Americans with Disabilities Act (ADA), R41280. 2011. [Cited June 6, 2020]. Available from: https://www.everycrsreport.com/reports/R41280.html. Continental Testing Services. Illinois Department of Financial and Professional Regulation: reasonable accommodation request for examinees with disabilities. 2018. [Cited June 6, 2020]. Available from: http://continentaltestinginc.com/wp-content/uploads/2018/07/IL_ADA.pdf. Little D. Learning differences, medical students, and the law. Acad Med. 2003;78(2):187–8. McDougle L, Mavis BE, Jeffe DB, Roberts NK, Ephgrave K, Hageman HL, Lypson ML, Thomas L, Andriole DA. Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt. Adv Health Sci Educ. 2013;18:279–89. Missouri State Board of Nursing. Position paper: requests for modifications from disabled candidates. 2002, September. [Cited June 6, 2020]. Available from: http://pr.mo.gov/boards/nursing/ NursingADAPositionPaper.pdf. Piltch D, Katz JW, Valles J. The Americans with Disabilities Act and professional licensing. Med Phys Disabil Law Reporter. 1993;17(5):556–62. Reaser A, Prevatt F, Petscher Y, Proctor B. The learning/study strategies of college students with ADHD. Psychol Sch. 2007;44(6):627–38. Sack W, Gale J, Gulati S, Gunther M, Nesheim R, Stoddard F, St. John R. Requesting accommodation for a disability: a telephone survey of American Medical Schools. J Postsecondary Educ Disabil. 2008;20(2):93–9. Settlement Agreement Between the United States of America and the National Board of Medical Examiners, #DJ 202-16-181, February 23, 2011. [Cited June 6, 2020]. Available from: https:// www.ada.gov/nbme.htm.

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Smith WT, Allen WL. Implications of the 2008 amendments to the Americans with Disabilities Act for medical education. Acad Med. 2011;86:768–72. United States Department of Education Office of Civil Rights website. Protecting students with disabilities. 2020. [Cited June 6, 2020]. Available from: https://www2.ed.gov/about/offices/ list/ocr/504faq.html.

Conclusion

This casebook has provided a variety of cases from medicine and nursing to illustrate how to apply the principles and concepts described in the book Disability Inclusion: Disability as Diversity. While the examples have been about medical and nursing students, these cases could easily apply to any health science student. We chose the cases carefully to represent typical situations the disability resource professional, faculty, or administrators might encounter and offered concrete suggestions for critically analyzing and addressing the case, reducing barriers to students with disabilities. This casebook companion to Disability Inclusion: Disability as Diversity should be on the shelf of every disability resource professional and health science academic administrator. Both books offer factual and reliable resources to investigate and improve accessibility as students with disabilities are welcomed into our academic communities.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4

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A ADA Amendment Act, 73 American Sign Language (ASL), 25 Americans with Disabilities Act (ADA), 98, 112 Association for Higher Education and Disability (AHEAD), 80 Association for Medical Professionals with Hearing Loss (AMPHL), 27 B Barker, C., 25–33 Board examinations accommodations, 143, 146, 148, 149 ADHD, 147 barriers, 144–145 current neuropsychological evaluation, 142 deconstructing barriers and access issues, 145–146 documentation, 147 learning new language, 141 non-passing scores, 142 3.5 GPA, 141 Burkess, T., 133–139 C Certified Nursing Assistant (CNA) certification, 117 Colon cancer accommodations, 58–60 ACGME guidance, 63 barriers, 56, 57 creating disability policy, 62 deconstructing barriers and access issues, 57 GME, 60, 62, 63

legal requirements, 64 medical appointments and treatments, 56 medical training, 56 Computer-assisted real-time transcription (CART), 26, 34 Connors, C., 3–6, 8–12 COVID-19 pandemic, 100 Crohn’s disease abdominal pain and occasional diarrhea, 47 accommodations, 51, 53 barriers, 48–49 chronic health conditions, 53 clinical competency committee meeting, 48 deconstructing barriers and access issues, 49–51 diarrhea, 48 disability, 52 student behavior, 52 Cued English transliterator services, 34 D Deafness accommodations, 99, 101–103 ADA, 100 audiogram records, 96 barriers, 96–97 deconstructing barriers and access issues, 97–99 GPA, 96 hearing aid, 95 livestream video, 103 nursing curriculum, 96 prelingually deafened, 95 reasonable accommodations, 98 student-centered approach, 100 Designated interpreter (DI) model, 27

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 L. Neal-Boylan, L. M. Meeks (eds.), Disability as Diversity, https://doi.org/10.1007/978-3-030-55886-4

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Index

156 Disability insurance, 43–45 Disability resource professional (DRP), 17, 27, 32, 71, 78, 87, 96, 134, 142 E Emotional support animals (ESAs), 134 F Fernandez, M., 55–64 Forearm accommodations, 87–90 barriers, 86–87 deconstructing barriers and access iIssues, 87–88 forearm, physical skills, 86 life long experience, 86 self-care and activities of daily living, 85 technical standards, 89 G Grade point averages (GPAs), 96 Graduate Medical Education (GME), 60, 62, 64 H Hampton, H., 47–53 Hearing loss accommodation needs, 26 barriers from designated interpreter, 28–29 DRP, 29 medical school, 28 student, 27–28 clinical accommodations chart, 34 closed captioned videos, 25 hearing loss clinical accommodations, 32 front row seating, 25 legal determinations, 34–35 nuanced and variable clinical environments, 32 outpatient clinical experience, 26 sign language, 27 small student-teacher ratio, 25 speech reading skills and intelligible speech, 29 speech therapy, 25 technical standards, 26, 31 transmitting microphone, 33 Howard, A., 95–104

I Individualized education plan (IEP), 77 J Jones, A., 127–131 L Learning disability academic challenges, 70 academic strengths and past challenges, 77 accommodation information, 81 accommodations, 72–74, 78, 81, 82 ADA, 73 baccalaureate program, 69 barriers, 70–71, 79 clinical accommodations, 80 deconstructing barriers and access issues, 71–73, 79–81 educational programs/workshops, 81 functional limitations, 72 self-efficacy, 74 simulation experiences, 72 technical standards, 81 test-taking environments, 82 unfair advantage, 78 web site and pamphlet, 70 M Martinez, M., 141–149 Mason, M., 77–82 Matthews, M., 109–113 Medical marijuana accommodation, 130, 131 barriers, 128 chronic illness, 127 clinical placement, 127 deconstructing barriers and access issues, 128–130 Federal law, 130 reasonable accommodations, 129–130 N Nacht, S., 117–123 Narcolepsy accommodations, 117, 121 barriers, 118–119 deconstructing barriers and access issues, 119–120 financial resources, 121 future nursing job, 121

Index math learning disability, 117 reasonable accommodations, 120 school aid and state aid, 120 technical standards, 122, 123 National nursing licensure board examination (NCLEX), 95 Note-taking services, 34 O Objective-structured clinical examinations (OSCEs), 8 Office of Disability Services (ODS), 134 P Personal protective equipment (PPE), 137 PTSD and depression address mental health concern, 41, 42 barriers DRP, 39 medical school, 39 student, 38–39 clinical accommodations, 42–43 clinical knowledge, 38 cooking lessons, 38 deconstructing barriers and access issues, 39–41 disability insurance, 43–45 medical school counseling, 38 Q Quadriplegia barriers DRP, 18 from faculty, 18 from student, 18 C6-C7 complete quadriplegic, 17 clinical accommodations, 21–23 didactic accommodations, 17 DRP with limited knowledge, 20, 21 3D printed cardiology stethoscope handle, 22 R Rapp, R., 37–44 Rehabilitation Act, 149 S Service animal ADA, 134, 138

157 barriers, 135 deconstructing barriers and access issues, 135–137 dog, 133 emotional support animal, 136–138 pets policy, 134 reasonable accommodations, 136–137 volunteer therapy dog, 134 Signed language and/or oral interpretation services, 34 Smith, M.S., 69–74 Stone, S., 85–90 Student Affairs (SA) Dean, 142 Suicidal ideation accommodations, 113 ADA, 113 anxiety and depression, 109–111 barriers, 110–111 deconstructing barriers and access issues, 111–112 “reasonable” accommodation, 112 3.0 GPA, 109 T Technical standards, 31 Thomas, T., 17–22 “Three strikes” policy, 143 Transparent surgical masks, 34 U Undiagnosed learning disabilities absence of documentation, 4 accommodations, 13 advocacy and “people skills”, 5 anticipated academic struggle, 10, 11 applying for accommodations, 4 campus partners, 7 clerkship director approaches, 5 clinical accommodations, 8, 9 completing practice questions, 4 deconstructing barriers and access issues, 6–8 drawing pathways, 4 family history of, 4 group’s conversations, 3 hand-writing, 4 institution and the student, resources for, 7–8 instructional methods, 11, 12 isolation and anxiety, 4 organizing notes in space and by color, 4 perceived barrier, 5

158 Undiagnosed learning disabilities (cont.) pre-clinical curriculum to clerkship curriculum, 9, 10 reading aloud, 4

Index socioeconomic barriers, 12, 13 utilizing review books, 4 watch lecture recordings at own pace, 3 written and verbal language processing, 4