Disabilities: The Next Chapter in DEI

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SPECIAL REPORT: ADVANCES IN PSYCHIATRY

When we consider diversity and inclusivity, it is important to think about disabilities, Donald Egan, MD, MPH, and Jessica Williams, MD, told attendees of the 2024 APA Annual Meeting.

Approximately 60% of US adults have a chronic disease, and 40% have 2 or more, Egan said. Additionally, 27% of US adults have reported they have a disability across a spectrum of areas (Figure). Egan is vice chair of the APA Diversity Leadership Fellowship and a PGY-3 resident at the University of Texas Southwestern Medical Center.

Figure. Types of Disabilities Reported by US Adults

Individuals with disabilities tend to experience frequent mental distress (ie, 14 or more mentally unhealthy days in the past 30 days) at a higher level than those who do not have disabilities, Egan and Williams reported. They added that data from 2018 indicated 32.9% of adults with disabilities reported mental distress, and that adults with disabilities are also 2 to 3 times more likely to experience suicidal ideation, suicide planning, and suicide attempts.

Yet, despite the high rates of disability, practical issues involving patients with disabilities are rarely discussed in medical school, said Williams, who is vice president elect of the APA Diversity Leadership Fellowship and a PGY-3 resident at Washington University School of Medicine in St Louis. The speakers polled the audience, who generally agreed that the topic is brought up quickly and equally quickly dismissed.

Practical Considerations

Cultural humility is necessary when working with patients with disabilities, Williams told attendees. The first issue, Egan explained, is to understand there are a few definitions and models of disability as well as different types of disabilities. The social model considers disability a “problem resulting from complex interaction of social and environmental conditions and a person’s impairment,” whereas the medical model considers it a “deficit/pathology residing in a person’s body [that] can be cured or treated,” Williams explained. It is also important to understand that disability does not equal handicap: “Disability refers to a reduction of function or the absence of a particular body part or organ, [and] a handicap is viewed as a disadvantage that limits or prevents fulfillment,” Egan added.

The types of disability are diverse, Egan told attendees. He categorized them into physical, sensory, and mental, with each category consisting of different issues such as function/mobility, invisible illnesses (eg, chronic pain, fibromyalgia, etc), neurodiversity (eg, attention-deficit/hyperactivity disorder, dyslexia), intellectual/developmental, and psychiatric.

Williams and Egan also shared tips for culturally competent care for patients with disabilities. “Be curious, supportive, and receptive,” Williams said. Identify any biases you may have and then explore those biases, Egan added. Consider every aspect of the care encounter. Is your office accessible? Can wheelchairs navigate the waiting room, exam/treatment rooms, and bathrooms? Do you allow virtual visits in addition to in-person visits? Does the intake form inquire about the disability and what the disability means to the patient?

It is important to also ensure screening and treatment plans are culturally competent, they said. Assessments can be sensitive and complicated, Egan explained. Symptoms may present differently, Williams added, and some patients may downplay the disability’s impact. They reminded attendees to check for special issues unique to the patient’s disability, such as potential drug-drug interactions. Williams and Egan also stressed the importance of conducting all pertinent screenings regularly scheduled for patients without a disability. For example, don’t think that just because a patient has Down syndrome that they are not sexually active. Propose and discuss a treatment plan, making sure the patient understands it and can adhere to it. “Remember: Patients are experts on themselves,” Williams said.

Disabilities in Clinicians

Clinicians also may have disabilities, Williams and Egan noted, but not at the same rate as in the general population. This statistic is partially due to the lack of data, they added. Despite the Americans With Disabilities Act of 1990, Williams told attendees that the 2010 Association of American Medical Colleges Diversity in the Physician Workforce failed to examine and report data on the number of clinicians with disabilities. And in 2015, there still was no means to determine and report the number of medical students with disabilities, she added.

Both Egan and Williams pointed to medical schools’ faulty technical standards, which are often difficult to find and focus on sensorimotor skills as opposed to cognitive abilities, with a more functional standard focusing on competency outcomes regardless of how a student achieves such.

Williams disclosed to the group that she identifies as deaf and hard of hearing, and Egan shared that he has cerebral palsy. They detailed their struggles in negotiating accommodations throughout their medical education. Williams further shared her frustrations about the lack of resources and guidance, noting she originally thought she was the first medical student with hearing impairment.

Concluding Thoughts

Egan and Williams pointed to a bidirectional relationship that needs to be considered to improve cultural competence for patients and opportunities for aspiring clinicians. Increasing diversity will lead to increased opportunities to better understand and support patients, they said. If curricula on disability increase, the perspective and flexibility of clinicians increase, which may also lead to an increased number of students with disabilities admitted to medical school.

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