Fostering Belonging: Perceptions of Disability Inclusion in Medical Education Among Students With Disabilities

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On this episode of the Academic Medicine Podcast, Neera Jain, PhD, MS, and Erene Stergiopoulos, MD, MA, join host Toni Gallo to discuss their new study of the experiences of students with disabilities during the first 2 years of medical school, which is part of this year’s Research in Medical Education (RIME) collection. Also joining the conversation are RIME Committee member Andrea Leep Hunderfund, MD, MHPE, and AAMC MedEdSCHOLAR Rosaysela Santos, PhD.

This episode is the first in this year’s 3-part series of discussions with RIME authors about their medical education research and its implications for the field. Check back next month for the next episode in the series.

This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.

A transcript is below.

Read the article discussed in this episode: 

Expand your thinking about disability inclusion. Check out these other conversations with researchers, leaders, learners, and advocates.

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Transcript

Toni Gallo:

Welcome to the Academic Medicine Podcast. I’m Toni Gallo. Every year Academic Medicine publishes the proceedings of the annual Research in Medical Education, or RIME, sessions that take place at the AAMC’s Learn Serve Lead Meeting. This year, the RIME papers, including the one we’ll be talking about today, will be presented throughout the Learn Serve Lead meeting, which is taking place in Atlanta in November. The RIME papers are available now to read for free on academicmedicine.org. As in previous years, I’ll be talking to some of the RIME authors on this podcast about their medical education research, and its implications for the field. Today, for the first of this year’s RIME conversations, I’m joined by Drs. Neera Jain and Erene Stergiopoulos, two of the authors of “We need a Seismic Shift: Disabled Student Perspectives on Disability Inclusion in U.S. Medical Education.” Joining us today for our conversation are RIME Committee member Dr. Andrea Leep and MedEdScholar Dr. Rosaysela Santos.

We’ll talk about Neera’s and Erene’s study, what they learned about students with disabilities who did versus those who didn’t request accommodations during medical school and ways to foster belonging and create a welcoming, inclusive medical school environment, where students with disabilities can thrive.

Before we do our introductions though, I want to mention two other podcast episodes that you all might be interested in. Last month on this podcast, I spoke to Drs. Teresa Papich, Lisa Meeks, and Tim Gilbert about ways to create an accessible and inclusive clinical learning environment for medical students. Then Dr. David Skorton, Amy Addams, and Mytien Nguyen joined a recent episode of the Docs with Disabilities podcast to discuss burnout, mental health, and well-being in physician learners. You can find both of those episodes wherever you get your podcasts. The links are also in the show notes for today’s episode.

So with that, let’s meet the guests on our episode today. Neera, Erene, you want to go first?

Neera Jain:

Sure. Kia ora koutou. Hello everyone. My name is Dr. Neera Jain. I am a senior lecturer at the Center for Medical and Health Sciences Education at Waipapa Taumata Rau, the University of Auckland in New Zealand.

Erene Stergiopoulos:

Hi everyone. I’m Erene Stergiopoulos. I’m a clinical fellow in psychiatry at the University of Toronto, where my fellowship is in workplace mental health and accessibility. I’m also doing a PhD in Health Professions Education research at the University of Toronto as a fellow at the Wilson Center. Happy to be here.

Toni Gallo:

Welcome to both of you. Andrea, Rosie…

Andrea Leep Hunderfund:

Hi, I’m Andrea Leap-Hunderfund. I’m a neurologist at the Mayo Clinic in Rochester, Minnesota, and medical director of our office for applied scholarship in education science.

Rosaysela Santos:

Hi, my name is Rosaysela Santos. I’m an assistant professor at the Kaiser Permanente Bernard J. Tyson School of Medicine. I’m an anatomist by training, but I am also the co-chair of our EINC committee and the faculty advisor for our student disability affinity group.

Toni Gallo:

Thanks so much for joining us today. Neera, Erene, I want to start with you. Could you tell us about your study? What was your methodology, maybe how it was unique, and then some key findings that you think our listeners would be interested in?

Neera Jain:

Sure. So our study is a qualitative analysis of data from the Year 2 Questionnaire that is administered by the AAMC to all second year medical students in the U.S., and we analyzed data from an open text question from the 2019 and 2020 cohorts of responses. And the question that they were responding to, if a student said that they have a disability, they were prompted to answer the question, “Use the space below if you’d like to share anything about your experiences regarding disability and medical school.” So they were asked if they had a disability and whether they were using accommodations, and why or why not. And then there was this open text question. So we were analyzing that open text data from those two years, and we used thematic analysis, reflexive thematic analysis using a critical realist orientation to consider what those responses could tell us about the workings of disability inclusion in U.S. medical education.

And I think there’s a couple of things that are unique about this data. First is that it captured responses from students who do and don’t use accommodations. And a lot of the research that’s been done thus far has focused on students who use accommodations. So qualitative studies that have been done have largely been interview studies, and so students put themselves forward to respond to that, and either due to the structure of those studies or who comes forward, largely, the students who participate are students who use accommodations. So in this data set, we had more responses from folks who aren’t using accommodations.

And then just a little bit about the findings. Our analysis, we divide into two parts. The first part, through those responses, we could see that there were features of the medical education system at their school that mediated their experience. And we identified those as being the program structure, the processes for accessing accommodations and health care supports, the people they interacted with, so their teachers, their fellow students, administrators, and then the overall culture within the school and the wider society and medicine that they spoke about influencing their experiences.

And then in the second part of our analysis, we talk about how students described acting in response to the system that they encountered. And we saw that students use different strategies to navigate that system using administrative, social, and internal mechanisms. And so we used the political relational model of disability to make sense of those findings. And we suggest that disability experiences are determined by a complex assemblage of human and non-human interactions, which is a fancy way of saying that structure, culture, process, people, and the student’s own actions, all of that works together to create a disability experience. And yeah, maybe I’ll pause there. And Erene, I don’t know if you want to add to that.

Erene Stergiopoulos:

I think thinking about what this type of data collection method affords, it’s different from an in-depth interview, which is what you and I are both used to doing as qualitative researchers. And I think what we found was that the responses were incredibly varied. There were some that were a couple of words or one word, and there were others that were 284 words. That was the longest response we had. And what I think is incredible, and what we kept on talking about as we were going through this data, combing through all these swabs of data were that this is a very long survey. This is taking students a very long time to complete, and this question is appearing towards the end of that survey. So they’ve already gone through questions and questions and questions, and they’re still putting a ton of thought and reflection into these responses. And so we felt this incredible responsibility to actually report this data to actually make these voices heard, which is a big part of the, I think, the ethos behind this paper and wanting to make sure that people’s time and effort were really honored and respected.

Andrea Leep Hunderfund:

Can you talk a little bit about how this question came to be part of the Y2Q survey for listeners who’ve been in this space for a while and are familiar with the GQ or the Y2Q, there’s a backstory there.

Neera Jain:

Yeah, thanks for asking about that. And I should probably also highlight that Erene and I did this work with partners at Meeks Lab, which is led by Dr. Lisa Meeks at the University of Michigan, who runs the Docs with Disabilities Initiative. And it was Dr. Meeks and Dr. Moreland who’s the other senior author on this paper. They were the ones who worked with the AAMC to add these questions to the survey. And I think the two of them and a lot of us in the field really think about how can we get better data about the experiences of folks with disabilities? And Lisa’s been doing some prevalence work for a long time, and trying to map the numbers of students with disabilities in the U.S. and she’s been able to access that data through disability services offices at med schools and at universities. That data is of course limited because that’s who is registering with their disability service office.

So adding these questions to the Y2Q was a really groundbreaking, important move in the U.S., and I’ll just say is something that doesn’t exist in many other countries. So right now in New Zealand, we’re talking about how can we add this to similar kinds of surveys that happen. So it was advocacy and, certainly, a lot of work with numerous folks who crafted these questions. And so this was the first cohort of responses in 2019 to this disability information.

And I think it’s probably important to also say that that prevalence work that Lisa had done previously, I think the latest data, is it 4.6% that that data shows are registered with disability services, 4.6% of medical students? And this national survey shows about 9%. So we can see there is a big gap between the number of students who are registering and accessing services through their schools and who are saying, “I have a disability,” when asked on this national survey. So there’s a gap between those two numbers.

Rosaysela Santos:

I really appreciated that you provided the reader direct access to students’ comments, the data and the rawness of the data. That was just really fantastic for me as a reader. And I know that this analysis was more focused on students with disabilities, but I also saw that you were able to capture some of the voices of medical students that were seeking a diagnosis and accommodations for the first time in their lives. And I was wondering if you could speak to that or if you learned anything about this specific group.

Erene Stergiopoulos:

I think that medical school is such a time of intense learning where learners are for the first time confronted with a volume and intensity of learning that they have not experienced in their lives before. And I think that can be a key moment of actually realizing, “Oh, I’ve actually been using compensatory mechanisms my whole life,” especially for learning disabilities, ADHD, and, “Oh my God, I can’t make it anymore. I was able to make it, I could grit my teeth through my undergraduate university, maybe a Master’s degree, maybe a PhD.” So many people in medical school are so accomplished, and yet either the physical taxing or the emotional or the cognitive taxing of … nature of medical school just brings people’s realization to the fore. It’s like, “Oh, maybe there’s something about this environment that I cannot access.” So it’s interesting. I work clinically in psychiatry, so I see a lot of people questioning whether that’s in university, whether that’s in medical school, people who’ve been able to make it through their education so far.

So did we learn anything about this group? I think there’s a lot of people out there that are very silent in the system that don’t necessarily feel they’re able to go out there and get a diagnosis. If there aren’t services at the school, they might not necessarily be able to afford getting an assessment. In the U.S., you have to pay for it. I’m in Canada, so at least at the very least while there’s waiting times, we do have getting an assessment is free, or covered. And so there are lots and lots of barriers in place to even getting a diagnosis. I think that the data really opened our eyes to how much work there is to get the diagnosis in the first place.

Neera Jain:

And I think just to add to that, there were responses from students who described having a really easy process of accessing that diagnosis because the services were in place at their school, and/or because their school was open to working with them on a provisional basis while they sought that documentation and diagnosis that they needed. And that really reflects the best practice that comes out of organizations like AHED, the Association of Higher Education and Disability in the U.S., in terms of how we evaluate whether students are eligible for accommodations in higher education. But on the other hand, one of the strands that came through when I talked about process is that included access to medical care.

So as Erene was saying, the processes for getting the kind of paperwork you need, for example, for a learning disability diagnosis or for ADHD is quite extensive. And in particular, if they want to have diagnostic paperwork that’s going to serve them for the USMLE exams, they have to have extensive testing. And students described the amount of time and energy that it required for them to get testing. I am recalling, there’s a lot of quotes from this data, and I appreciate you recognizing the rawness of the data. We often use the phrase “the data is screaming,” and it was really important to us that these voices were uplifted through this work, but there’s a student response who said that they were told it’s a little bit late to be coming forward and asking for things after they had worked so hard and for so long to get an appointment to do this extensive testing. And then to be told, “Why are you coming to us now?” It’s like, “Well, this is the process that you have in place. It’s taken me a long time to secure the funding and to secure the paperwork you’ve asked for.” And that kind of frustration came through so clearly.

So I think one of the key messages of this paper is how different students’ experiences could be depending on the barriers that we put in place for them to access, and the recognition of that work that students are doing and being asked to do to manage their disability really. And that’s the phrase that we came to “manage their disability” in this environment.

Erene Stergiopoulos:

And there were students who saw how much work it would be, especially for USMLE accommodations, and just decided it’s not worth it though. They would just choose not to even go down that route because they saw how much that would involve in terms of work.

Toni Gallo:

Building on some of these experiences that you’re describing, you mentioned that a unique part of your data collection was you were able to get responses from students who did not request accommodations, which is usually a group that is not included in interviews or other kind of research that’s been done so far. What else did you learn about this group specifically and their experiences? And what might we take away from that as we’re thinking about the medical school environment and what’s working and what’s not working?

Neera Jain:

Yeah, I think this is really important because it was really multifaceted in what we saw through students’ responses. So as Erene just said, some just simply gave up. They either tried and found it so difficult, their schools were non-responsive, or they just looked at the process and said, “I can’t manage that on top of what’s required to be a medical student.” There was also stigma. So stigma came through really clearly, students being worried that they would be marked by their peers, by their teachers, by residency programs if they used accommodations. And then allied with this was this idea that in the future they wouldn’t be able to access accommodations. So as residents, even in the medical school clinical space, and then into the workplace, this feeling that I won’t be able to access accommodations there, so I better learn how to do it without those supports now.

So this idea of a duty to buck up and figure out how to fit. And then I think the other layer is that some just simply didn’t need accommodations, and this is really important to think about because some of those responses were telling us, literally, “I didn’t need accommodations because the environment was accessible.” So some students even described, “I was having a hard time, and then, for example, small group went online because of the pandemic, and all of a sudden I was doing great because I had easy access to a bathroom or I could hear everyone because there wasn’t this noisy background that was impeding my ability to hear.” Or, “All students get as much time as they need on exams so it’s not a problem for me. I can work within that system to use the time I need to express myself.” So it really was multifaceted and I think that gives us a stronger picture of the complexity of where we stand with students who don’t use accommodations.

Erene Stergiopoulos:

Just to build on that, there were a few responses that talked about managing their disability and saying like, “Look, I’m working with my doctor. I’m on a good regimen of treatment. I’m working with my physio, I’m working with my therapist. I don’t need accommodations.” But going back to this idea of how much work it is, and also the flexibility of the curriculum, you need time to go to your doctor, you need time to go to your therapist and your physio, and a lot of medical curricula are more than a full-time job. Where do people actually get the time and flexibility to attend those appointments? So that, again, drove home this idea that, “Oh, it’s possible.” There is a system, there is a world in which things can actually work for people and they can both help manage their disability, while also being a medical student at the same time.

Andrea Leep Hunderfund:

These reflections you’ve offered unpack one of the ideas that’s in the paper, which is that accommodations is one pathway to access. That’s a new idea to some. Could you unpack that further?

Neera Jain:

Sure. So yeah, accommodations are certainly the central way that most people think about creating access. And partly that’s because the ADA, the Americans with Disabilities Act, that’s what it requires of us, is to consider accommodations. And one of the limitations of an individual rights-based framework is that it advantages those who have access or proximity to power. So all the things we’ve been talking about. Have you had good health insurance? What kind of school system have you been in? What kind of freedom do you have to not be working on the side while you’re a medical student and therefore have more time than maybe other people do? There’s all these factors that go into who can access this rights-based system that we have, which requires providing extensive documentation, having a history of documentation, having an understanding of yourself. There’s also cultural dimensions that come into that.

And the alternative to that, which is something that comes out of architecture, a disabled architect coined the phrase universal design. And that idea has traveled into other spaces including education. And so universal design is an idea that, essentially, if you build flexibility and consider the diversity, the broad diversity of people who might be using a space or a thing, if we think of medical education as a thing, and we design with a broad diversity of people in mind that we will have built in the flexibility, the physical environments, the temporal time environments, the social environment that is designed with all kinds of people in mind.

And so that’s what we’re illustrating in the idea of how are physical environments laid out, how much time do people have, how much is it built into the system that we recognize disabled people will be here of all types, rather than individuals having to go forth and individually make a case for what they need, particularly when many of those people may not know that, “I qualify as a disabled person. These are the kinds of things I can ask for,” within a system where students, some might argue this is not true, but students have less power, they’re worried about the future. “What can I ask for? What’s going to be okay? How am I going to maintain my right to be here as a capable qualified student?” And that’s something that they’re always thinking about when they’re asking for accommodations. And again, you can imagine the kind of cultural and political dimensions of that, of who feels safe to ask, who asks for more, and who feels the right to push those issues with their schools.

Toni Gallo:

One of the other pieces that I think ties into this is the sense of belonging that some students expressed in their comments, or lack of belonging, and whether that was explicit pieces of the formal curriculum or whether it was implied aspects of the informal curriculum and the environment that they were in at their medical schools. And a number of the comments fell into this, “I feel welcome,” or, “I don’t feel welcome.” And could you both talk about that part of your study, and maybe some takeaways around how to create a more inclusive, welcoming medical school?

Erene Stergiopoulos:

A lot of people talked about unintentional disclosures of their disability, and that was often probably the most alienating experience that we could capture in this data. People talked about, for example, having extra time on an exam but then having to write in the same room as students without an accommodation. And so they were there for longer. And so it was very obvious the group of students who were accommodated, and so suddenly this part of their identity that they weren’t necessarily wanting to display to their whole class is fully on view. And those were moments that, in my mind, are the opposite of what we want to do to foster belonging. On one hand, you’re in the room with all of your peers, and on the other hand it’s not on your terms, and you’re not able to present yourself.

There’s a beautiful line from a paper by Justin Bullock “presenting yourself in all your forms.” And a lot of his work and that paper in particular deals so much with belonging and being able to express the multifaceted parts of our identities. So thinking about this data set in this paper, I think about the ways in which parts of people’s identities aren’t really expressible on their own terms, and how structures in place in our curricula, in the ways that accommodations are provided can take away that agency. So that’s both formal and hidden curriculum. When we think about hidden curriculum, we’re thinking about everything outside of what’s formally taught. So institutional policies, practices, institutional language, the taken for granted aspects of medical education.

So when I think for example about is there a designated disability service provider at that school who knows clinical environments and who’s able to provide expertise in accommodating students who are in clinical environments? If there isn’t, what are students going to get from that? They think, “Oh, maybe there’s no one else like me. Maybe it’s not even appropriate for me to be here because there’s no one who specialized in accommodating me in the way that I need.” So all of these can affect someone’s sense of belonging.

Neera Jain:

Just to add to that, there were some really interesting … I’m just thinking of a few quotes that really illustrated this issue of belonging in other ways than Erene has just mentioned. One was around student groups. So there was a real divergence when students talked about student groups where there were some responses that students talked about this very issue of belonging and of being frustrated and angry about the systems that they were encountering. And they had started communities at their schools among disabled students where they were working together on those ideas, but also providing support to each other, creating community around disability. And that was really powerful. And I’m thinking of a student who also responded saying their faculty made pejorative comments about disabled patients, and that had really contributed to that idea that disabled people aren’t here in the classroom, don’t belong in this space, and we don’t like them.

And so these kinds of communities were spaces where students could belong, could share their experiences, could change systems. And that really contrasted with, there were a few responses from students who said that they went to other places. There was one who said they went to a conference and they met other disabled people, and it was the first time that they really had found their people and that they felt so alienated at their medical school because they came back and they said something like, “It’s unspeakable here, I can’t talk about it. Nobody talks about it.” And another response was talking about just wanting that community so deeply.

So I think communities are certainly a place of belonging, but also other really simple things like there was a response where a student said, “I can’t tell you how many times I’ve asked for gluten-free food at school events, and they just won’t provide it, and I’m tired of asking for it.” And that’s a really simple thing that I think these days we would think is fairly straightforward access to provide dietary requirements, and yet they just had become exhausted asking for that.

I think one other thing that is more part of an explicit curriculum that was mentioned probably more times than I would’ve expected with students talking about mental health panels at their medical school. And if you’re not familiar with those, it’s something that happens in the curriculum where there’s a panel of people, usually including more senior medical students, faculty, and others talking about their own personal mental health experiences. And I think there’s a quote we include in the paper where a student talks about how that experience gave them the courage and the permission to seek a diagnosis to access treatment and to access, I think they say access accommodations as well.

So we can see these contrasting kind of experiences of where it becomes permissible to declare a disability, to identify with others, to have that community to, as Erene says, that beautiful quote from Justin Bullock’s work, be yourself in all your forms. And really contrasting with places where that was just constantly driven home that that’s not okay, that’s not us. And that really shaped students’ experiences profoundly.

Rosaysela Santos:

Really appreciate you both sharing all of these ideas and initiatives. I think they’re really wonderful, and I know I’m definitely going to take some of this back to my campus, but in thinking of inclusion and the culture of belonging, as an educator, it surprised me to learn how much impact one individual, just one individual can have on the culture of inclusion. And this seems to come up as a recurring theme in students’ comments. And for me, I take this as a huge responsibility, but also an honor. But I was wondering, did the study change your perspective on your roles as an educator in medical education? Thank you.

Neera Jain:

Yeah, I’m happy to speak to that. Yeah, I think it’s something we recognized early. So historically, I worked in student disability services. That’s what led me to do my PhD and to become a researcher in the space. And it was something that I knew intuitively, that getting a champion, having people who know the system, who can shepherd students through the system, who can be the safe place for students to come with their experiences can be revolutionary for students. And we saw that so clearly in the responses, where so often when students had a good experience, they named the person, it was taken out in the data that we received, but it was clear that there was a person. Or they would say, “My dean,” or, “The student disability services person,” is incredible. And sometimes they said that person is incredible and is making things happen when other people don’t. And that’s a really important thing to think about.

But I think the other side of that, and I think it’s this tension, we really need champions, and also we need more than singular heroes to shift this. And I think what you say about that responsibility is so important because one really bad experience can also send a student underground, so to speak, and that can be the message that tells them, “It’s not okay, I can’t be like this. No one can do anything for me.” And so I think that’s where if there are champions out there who want to support this work, part of that work is ensuring that people are educated and getting other people on board to understand their responsibilities, to have a good sense of what’s available at a school, the diversity of experiences that count as disability, the kinds of accommodations that are possible, because we hope that students’ first encounter will be with that champion, but if they’re not with that champion, that can be something that is the end of the road for that student.

Yeah, it’s a huge responsibility. And now as a medical educator myself, that’s something that I think about in my teaching, I talk about it, I’m trying to extend that knowledge across my colleagues. And actually at the moment, my biggest teaching role is in a clinical education program. So I’m teaching current health professionals who work as clinical educators to be better teachers, to enhance their teaching skills. And I see this as part of that work, in the New Zealand context, is to broaden that group of champions who can be out there. So it’s a real privilege to be doing that work.

Erene Stergiopoulos:

I think the students are often afraid of needing too much, of being too much, of requiring what they think of as special treatment. And so I think they experienced this huge wave of relief when they can encounter someone who’s welcoming and validating and says, “Yeah, we can do that. Yeah, that’s not a big issue.” There was one comment in the data that was someone who requested accommodations and then, by the end of the day, they got them. And so that really showed me, at a personal level, it’s possible. My jaw drops when I realized, “Oh my God, all of the red tape that we imagine as just a feature of medical school and of the system that I’m part of, as well.” I have taught medical students and residents. I’ve been a medical student and a resident. It is just sort of you know the system that you’ve grown up in. You think, “Oh, it’s the only way of doing things.” Seeing what was possible opened my eyes to the kind of system that I want to be working in. It made me sort of think much more like what can I do in small ways to change the system? How about making the accommodations process really transparent? What can we do to communicate to residents, to medical students, to every level of the training pathway to make sure people actually have the knowledge that they need to be able to get their needs met?

Toni Gallo:

I want to encourage listeners, if you have not listened to our August episode, we talk about a case study that walks through an example of a student needing accommodations during her OB-GYN clerkship, and all of the different people who are involved at the medical school, the timeline, lessons learned. So if you’re interested in what an accommodations process could look like, check out that episode and the accompanying paper that’s in Academic Medicine.

Andrea Leep Hunderfund:

I wanted to offer a question on the other side, of where you spoke earlier about students who haven’t maybe encountered the disability and they are currently during medical school, or who have chosen for various reasons not to disclose or not to seek accommodations. As a faculty member, what are some things I can do to create a welcoming environment for someone to share or to ask or to bring it up if that’s the right thing for them to do in that moment? Are there proactive things? Asking in part because, sometimes, I encounter these things through mistakes. You gave the whole quiz with red and green pins in the anatomic structures and I couldn’t tell the colors apart, or going around the circle in a small group asking students to read a slide and then coming into an awkward situation with someone with a visual or a dyslexia type challenge. So curious what advice you’d have for faculty on that proactive side.

Neera Jain:

Sure. Thank you for that question. I think it’s really important and aligns with that universal design approach. So one of the first things that I would say is, potentially, to see if there’s someone at your institution who might be willing to audit your course materials or to talk through what you do and to think through ways that that design could be more flexible. So thinking about things like are you using color? What kinds of assessments do you use? What are your materials for that course? What’s required? And can we think through how to make those accessible from the jump? And that might be somebody from your student disability services office. Hopefully, they’re not too overtaxed that they might have time to do that work with you. And honestly, one of the things that I think about when I used to work in disability services is that so often we were putting out fires, like trying to retrofit accessibility into things that faculty wanted to do into our physical environments in response to a student.

And that’s the worst time to be doing it because you’re under a time crunch. You don’t want a student waiting for materials. You don’t want to be trying to get an architect to fix something at the last minute. You want to do that when you have the time to do it. So that would be one piece of advice. And then I think the other piece is communicating your openness, your expectation that students with disabilities will be in your courses. And sometimes that’s like on your first day or in your syllabus, or your course page, however you communicate with students saying, “I expect there will be students with disabilities in my class. I’ve endeavored to make this class accessible, but I welcome any feedback about how I can make additional adjustments to the material. Here’s the information for student disability services.” You might include a definition of disability and the kinds of accommodations that might be available. So going to that level of information I think is really helpful, and welcoming students coming to talk to you about any barriers that they might encounter in your course or that they anticipate.

And sometimes faculty do things, and it depends how many students you’re talking about, but having check-ins with students, maybe looking to see at certain points in the semester where there are students who are maybe struggling a little bit and just having a one-on-one conversation to just say, “Hey, how’s it going? I noticed that you’re da da da da, and is there anything I can do to support you in that way?” So there’s different strategies you can take, but I think always conveying that openness, conveying that expectation that disabled people are here. “I know you’re here. Come talk to me if there’s anything I can do to make the course more accessible.”

Toni Gallo:

I want to give everyone a chance. We’ll go around the room. If you have any final thoughts you want to share, or something for listeners, key takeaways, something else that you’re thinking about with this study, even next steps where this work could go from here. I’ll give everybody a chance to share their final thoughts. Andrea, you want to go first? And then we’ll do Rosie, Erene, and Neera.

Andrea Leep Hunderfund:

Sure. So I want to give a shout-out to listeners to read the paper because the quotes and the writing is beautiful. And one of my favorite phrases in the discussion talks about how you took a pointillist qualitative approach. And as a researcher, we often think, “Oh, an open-ended question on a survey, especially one at the very end.” You’re not going to have something to do that, that rich qualitative work. I really, really appreciated the analogy you used there and wondered if you might speak just a bit about where that idea came from.

Neera Jain:

Thanks for asking that. Erene and I love to develop metaphors to try to make sense of our data, and some of them land and some of them really don’t. I think one of our favorite metaphors while we were analyzing this was a soup metaphor, but it didn’t make it into the paper. But the idea of pointillism, I think, really comes out of that idea of what can we do with these moment-in-time, one response from a student? And Erene already mentioned the kind of real variety in what students said, and I just want to note that a one word response from one student was just diabolical, period. That was it. And that resonates with meaning. We don’t get the backstory, but it tells us something. And so the combination of the breadth of responses that we were getting, the depth in some cases, but in other cases, just this shiny piece of information that was so telling, it made us think of pointillism, the art movement of pointillism, and this idea that all of these points of data, some of them larger than others, some of them more clustered than others, started to develop this broader picture of a landscape of student experiences than what we had seen before.

So to us, that felt like a justification for calling this qualitative research, but also recognizing the limitations. Some areas are more dense and clear than others, and some are still yet to be filled in. So thank you for recognizing that. That’s one of the things that we love thinking about the methods for this paper.

Rosaysela Santos:

So I really, really appreciated what you said about having open door policies and just allowing students to reach out, but also making sure that the students are aware that you are open to receiving such messaging, and coming from a pretty new medical institution, so we are not very old. We are still learning, and I feel like that’s okay. Our institution is still growing and learning, and adjusting where necessary. And so I just wanted to leave that out there, that even if for those listeners that are listening right now and that maybe don’t know all of the accommodation process, it’s okay to say, “Come to me,” because then you can reach out, and so we can be a connector. And so I don’t know all of the accommodation process, but I can send a student in the right direction and also advocate for them. So I just really wanted to thank you for calling that out.

Erene Stergiopoulos:

When I think about where medical education is going in the future, competency-based medical education is huge. We’re implementing it in Canada across our medical schools. It’s already been implemented in residency programs. And I think that it presents a really important opportunity for more universal design principles to really take root in medical education. Because I think about when I went through medical school, and if you had three sick days in a row on a clinical rotation, you had to make up that time because, apparently, you can’t know internal medicine if you missed three days out of the two-month rotation or the eight-week rotation. And so competency-based medical education offers the opportunity if implemented in a thoughtful way, in a reflexive way, to potentially take some of the time pressures and the rigidity out of a lot of the way we organize medical education, because I think time is such a valuable currency for students, and it’s something we saw in the data, as well. I think we all see it in our working lives, and if we can take some of that pressure off where it’s like, as long as you can perform these competencies, we can be flexible about how we think about accommodations, time, going early to an appointment one day a week, because that’s something that’s important for maintaining your health and normalizing that. I think that would be an amazing step for medical education moving forward.

Neera Jain:

Yeah, I think for me, one of the things to think about with this paper is that in some ways it didn’t tell us things that were really new to us. And maybe that’s because the authors of the paper, we’re all pretty immersed in the space. It’s a state of the system kind of paper that really tells us the breadth of student experiences. And I think what Erene said earlier about the possibility that some of these responses reflected, I think about the idea of possible worlds and possible futures that we might have, and some of those futures are already here. It’s happening. It’s possible. And I think that’s where the idea that this the political relational model offers us, is that the really not great experiences students had is not how it has to be. It can be a lot better. And even we can think further. This idea of creating flexibility, creating more space. We’re making progress, there’s a lot more progress to make across the country, and, I would say, internationally as well.

I’m just getting some research started in New Zealand that will be one of the first qualitative studies of disabled medical students in New Zealand. And I think what we know in the U.S. is a lot deeper and broader than what is recorded in the New Zealand context. And so we have a lot to learn from the U.S., but also I’m hoping that, as this movement grows internationally, we can learn from each other. We can make some leapfrog gains in this space, and we still have work to do, but there are some great things happening.

Toni Gallo:

I want to thank you all for being on the podcast today and for this really rich discussion. This is a great way to expand what was in your paper. And for those listening, definitely check out Erene’s and Neera’s paper, which is on academicmedicine.org right now. You can find the full text for free. So go check out that article and all of the articles that are in this year’s RIME collection, those are all available now to read. So thank you so much.

Make sure that you check back next month for the next episode in this year’s RIME series, I’ll be talking to the authors of a qualitative study of medical students experiences of failure and remediation.

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