When Reasonable Accommodations are Unreasonable

When Reasonable Accommodations are Unreasonable

Discourses regarding accommodations for work and education ubiquitously pair “accommodations” with the modifier “reasonable,” echoing language in the Americans with Disabilities Act (1990) and its Amendment Act (2008). Indeed, an entire subsection is titled “reasonable accommodations and modifications" (Americans with Disabilities Act of 1990,as Amended with ADA Amendments Act of 2008, n.d.). Disability rights organizations, government websites on the ADA, and guidance for school administrative and disability officials all employ the discourse of “reasonable accommodation(s).” This, of course, implicitly leaves room for unreasonable accommodations—and gives rise to many court cases and internal institutional disputes about what constitutes a reasonable and necessary accommodation. Legal interpretation and precedent, expert medical opinion, institutional culture, and the nature of barriers themselves all shaped—and shape—the configuration and outcomes of disputes over accommodation requests and denials since the passage of the ADA (and indeed before).

The role of institutional culture is visible in the recent history of accommodations—namely, the high rate of refusals and resistance—in medical schools, institutions, and by the United States Medical Licensing Examination (USMLE) organization, the national organization that administers the “Step” exams required for all those on the MD and DO tracks (Bagenstos, 2016; Jain, n.d.; L. M. Meeks et al., 2020; L. M. Meeks & Jain, 2018; L. Meeks & Neal-Boylan, 2020; Petersen et al., 2022). The dominant culture of medicine has valorized stoic independence and consistently stigmatized disability and the need for aids of any kind (including breaks, sleep, food, and other necessities) for so long that the depth and reach of this ideology of ableist superhuman individualism can be taken for reality and be  invisible to many (B. Good, 1994; M.-J. D. Good, 1999; Martin-Lockhart, 2022; Stergiopoulos et al., 2018). Even following the ADA (1990), ADA-AA (2008), and the increasing presence of disability services, disability groups, and disability cultural centers on university campuses and in medical schools, medical students and residents frequently complain of a traditionalist attitude towards the hardships of medical education (Martin-Lockhart, 2022). This attitude holds that because prior generations of physicians were shaped by particular procedures and difficulties the next generation must experience the same. Thus, some attending physicians or medical institutions broadly will question the necessity of accommodations or worry that they lesson the rigor of a program instead of recognizing that accommodations help to equalize participation and evaluations of performance. Moreover, the ADA’s legal requirements are still relatively unknown to physicians, including educators  (Martin-Lockhart, 2022; L. Meeks & Jain, 2018; L. M. Meeks et al., 2020; L. Meeks & Neal-Boylan, 2020). Because of this many necessary and minimal accommodations are questioned or rejected as unreasonable—simply due to the ableism baked into dominant medical culture, norms, and bodies of knowledge.

The culture of rugged independence is glimpsed in the inflexibility of many schools’ technical standards, which bar accommodations and keep many otherwise qualified candidates from entering medicine (L. Meeks & Jain, 2016; L. M. Meeks et al., 2020). The ableism of medical culture is visible too in the continuing emphasis on exams and individual evaluations that are required for MD and DO trainees to progress and are important to match ranking and hiring decisions (Martin-Lockhart, 2022). The constancy of examinations and varied training environment requires trainees to constantly re-negotiate and repeatedly prove their need for accommodations (L. Meeks & Jain, 2018, 2016; L. M. Meeks et al., 2020; L. Meeks & Neal-Boylan, 2020). Quantitative measurements and details of accommodations refusals (legal and illegal) were historically hard to come by—particularly before legal protections were put in place. In 2022 data is only beginning to emerge. However, in 2022 the first measure of Step 1 (examination) accommodations grants/denials was published (Petersen et al., 2022). This work marked a seminal moment in disability awareness—though perhaps not inclusion—in US medicine writ large. The team found that in 2018-2019, 52% of 276 students counted in survey did not receive any accommodations requested, resulting in delays, a markedly higher rate of failing scores, and even program dismissal/withdrawal (ibid).

More than 15 years after the passage of the ADA and a decade after it was amended, appropriate accommodations are inappropriately denied and unreasonably difficult to attain. Many reasonable accommodations requested by medical students and practitioners are rejected or characterized as unreasonable. However, even this cursory exploration of how accommodations requests have been dealt with by medical institutions since the passage of the ADA indicates an alternative framing: perhaps it is the barriers to and refusals of accommodations, not the requests for them, that are unreasonable.

Americans with Disabilities Act of 1990,as Amended with ADA Amendments Act of 2008, Pub. L. No. 110–325. Retrieved April 30, 2022, from https://www.ada.gov/pubs/adastatute08.htm

Bagenstos, S. R. (2016). Technical Standards and Lawsuits Involving Accommodations for Health Professions Students. AMA Journal of Ethics, 18(10), 1010–1016. https://doi.org/10.1001/journalofethics.2016.18.10.hlaw1-1610

Good, B. (1994). Medicine, rationality, and experience: An anthropological perspective. Cambridge University Press.

Good, M.-J. D. (1999). American medicine: The quest for competence. University of California Press.

Jain, N. (n.d.). Clinical Accommodations: Upholding Standards While Creating Equal Access. AAMC. Retrieved May 3, 2022, from https://www.aamc.org/professional-development/affinity-groups/gsa/webinars/clinical-accommodations

Martin-Lockhart, Z. (2022). Disabled Doctors Dissertation Fieldwork [manuscript in preparation].

Meeks, L., & Jain, N. (2018). Accessibility, Inclusion, and Action in Medical Education: Lived Experiences of Learners and Physicians With Disabilities,. AAMC.

Meeks, L., & Jain, N. R. (Eds.). (2016). The guide to assisting students with disabilities: Equal access in health science and professional education. Springer Publishing Company.

Meeks, L. M., & Jain, N. R. (2018). Accommodating chronic health conditions in medical education. Disability Compliance for Higher Education, 23(10), 1–6. https://doi.org/10.1002/dhe.30432

Meeks, L. M., Jain, N. R., & Laird, E. P. (2020). Equal Access for Students with Disabilities: The Guide for Health Science and Professional Education (2nd edition). Springer Publishing Company, LLC.

Meeks, L., & Neal-Boylan, L. (2020). Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing, and the Health Professions.

Petersen, K. H., Jain, N. R., Case, B., Jain, S., & Meeks, L. M. (2022). Impact of USMLE Step-1 accommodation denial on US medical schools: A national survey. PLOS ONE, 17(4), e0266685. https://doi.org/10.1371/journal.pone.0266685

Stergiopoulos, E., Fernando, O., & Martimianakis, M. A. (2018). “Being on Both Sides”: Canadian Medical Students’ Experiences With Disability, the Hidden Curriculum, and Professional Identity Construction. Academic Medicine, 93(10), 1550–1559. https://doi.org/10.1097/ACM.0000000000002300