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Barriers Are Toppling For Medical Students With Physical Disabilities

Editor's Note: Editor's Note: This article is reprinted from the International Herald Tribune, November 27, 2003.

NEW YORK--As a fourth-year medical student, Jeffrey Lawler listens --really listens --as his patients run through their lists of physical complaints. When he touches a scar or feels for bumps, lumps or growths, he directs all of his focus into his hands, moving his fingertips slowly over skin, tissue and bone, occasionally pressing and prodding gently. A talking blood pressure cuff recites readings in an automated voice, and a nurse or fellow medical student lets Lawler know that a patient's temperature is hovering around 100.

Lawler's hearing and sense of touch are extra-finely tuned, because he cannot look into a patient's eyes or see if a wound has healed. He cannot read the numbers on a thermometer, a blood pressure monitor or his pager. His eyesight began fading 20 years ago, as a result of the disease retinitis pigmentosa. By 1993, Lawler, now 43, was legally blind. Still, he took the medical college application test with the help of a reader and a scribe and was accepted to Western University Medical School in Pomona, California. He will graduate in June near the top of his class and hopes to practice physical medicine and rehabilitation.

"The human body fascinates me, but my greatest strength as a doctor is patient contact," said Lawler, who is rarely without his guide dog, Burke. "Yes, my knowledge is good, but I also bring empathy to the bedside. I've been treated by doctors who didn't really listen to me or said things like 'You're not planning on having children are you?' So I take my time with patients and try and really listen and thoroughly explain things."

In the past, students with physical disabilities were rarely accepted to American medical schools, and those who were rarely completed it. But Lawler has joined a growing number of students with disabilities who are thriving in medical school.

Though no statistics document how many disabled students are attending medical school or how many disabled doctors are practicing, experts in the field note that laws like the Americans With Disabilities Act of 1990 allowed disabled students access to every level of education and helped propel the increase in medical students.

"Over the past several decades, the doors have opened for kids with disabilities to go to school, get diplomas and graduate, so we've seen huge increases in the numbers of disabled students in undergrad," said Martha Smith, project coordinator of the Centre on Self-Determination of Oregon Health & Science University.

A survey of the American Council on Education notes that the number of full-time freshmen with disabilities has increased to 11 percent from 7 percent from 1988 to 1999. Smith and colleagues at the Centre on Self-Determination have trained faculty and staff at about 25 medical schools in the last three years, focusing on ways to accommodate the students without sacrificing medical standards and patient safety. But despite increased acceptance of people with disabilities and changes in laws, attitudes may still be hard to sway, particularly in medicine.

"Doctors are the least comfortable and often the least knowledgeable about disability issues," said Julie Madorsky, 58, who practiced from 1969 to 1995. She had childhood polio and was the prototype for the character Kerry Weaver, the attending physician who walks with the aid of a crutch on the television series "E.R." She added: "There's a concept that it's 'them' and 'us.' The idea that someone can enter medicine with a physical disability is counterintuitive. It goes against the notion that doctors are healthy and perfect and able-bodied and patients are not."

Some people in the field worry that the physically disabled cannot fulfill the clinical requirements of medical school, and that they need special treatment to graduate. There is no national criterion for technical standards for admission and graduation, and each of the nation's 126 medical schools is responsible for creating and publishing its own graduation requirements.

"It's very tricky," said Robert Sabalis, associate vice president of student affairs and programs at the Association of American Medical Colleges in Washington. The organization soon plans to produce an updated overview of legal requirements for disabled medical students. "Some medical schools, for example, say that one cannot rely on the physical skills of a third party for assistance, but other schools don't have that."

Advocates for disabled students argue that some medical school standards that create hurdles for the disabled are outmoded. "Too many schools are using the standard that a doctor has to see perfectly, walk perfectly and hear perfectly, but if they really followed that standard, no one would graduate," said Brenda Premo, director of the four-year-old Centre for Disability Issues and the Health Professions at Western University.

The disabilities legislation may have had other influences as well. No studies have looked at malpractice and whether disabled doctors and medical students are at higher risk. But according to the Physician Insurers Association of America, a trade association of medical malpractice insurance companies, there is no difference in underwriting medical liability policies for doctors who are disabled and those who are not.

"Our application and underwriting process is blind to disabilities," said Frank O'Neil, a senior vice president at the ProAssurance Corp., one of the nation's largest medical liability insurers. "As long as a doctor is trained and able to perform the procedures for which they are applying for coverage --with or without an accommodation, like a physician extender --we don't care."

Lawler, the student, said he had a hard time getting a surgery rotation, a medical school requirement, because of his blindness. "Me being in the operating room became a big issue," he said. "In the third year, you don't do anything except hold retractors during surgery, but it was very challenging finding a site where I'd be accepted. Finally, I was able to scrub in on a procedure, and I was extremely focused. All I did was hold the retractor like old medical students do to keep the cavity open, but I really concentrated because I knew I was under a microscope and didn't want to screw up."

Lawler said he trained with a physician who was also blind, Stanley Yarnell, who practiced rehabilitation medicine in the San Francisco area for 27 years before retiring in June. Yarnell, 55, who began losing his vision in 1969 because of recurrent optic neuritis, said he considered medicine to be a cognitive process. "When I can't see something, I was able to get what I need in terms of a description from a resident, nurse or even a patient," Yarnell said. "But there are other low-tech ways to practice without vision."

Margaret Stineman, an associate professor of rehabilitation medicine at the University of Pennsylvania, was born with a deformity of the skeletal system, a reduced lung capacity and missing muscles to move her eyes. She consults on rehabilitation of patients with neurological injuries.

"I look for settings where my mind and creativity are valued," she said, "because these are the two particular gifts I have." She said that early in her career, some mentors were concerned that she might have difficulty getting through medical school. To her knowledge, however, "there has never been a patient who has been uncomfortable with my disabilities," she said. "I work in a trauma service, and as a person who has lived with disabilities, I can help my patients figure out how to develop ways to overcome their physical problems and grow. The life experiences that I've had are part of what I bring to patients, and they appreciate that."