In the third and final article in their series, Deborah Cohen and Karen Hebert look into the training requirements for doctors and medical students with disabilities and the barriers they currently face
Heidi Cox, a medical student at St George's Hospital Medical School, had to leave university in 1992 after an accident left her disabled. She decided to resume her training seven years later. She wanted to be a pathologist and got a place at Oxford medical school, on a course specifically adapted to her needs. However, her hopes were dashed when the General Medical Council informed Oxford that it could not approve a specially adapted course that would result in the achievement of a lesser degree of skill and knowledge. With the backing of the Disability Rights Commission, Heidi won the right to take the GMC to a discrimination employment tribunal, after a London tribunal ruled that “the GMC (as a trade organisation) was subject to the Disability Discrimination Act.” However, the GMC successfully appealed against this, with the tribunal stating that the GMC was a body responsible for prescribing and maintaining professional standards of expertise and was not a trade organisation.
That was then... this is now
At the time, qualification bodies did not fall under the Disability Discrimination Act. From 1 October 2004 they do, which means potential changes for Heidi and other disabled students who wish to become doctors.
Although the act covers employment, a disabled person's prospects of getting or retaining a job or of progression in work may be hampered if he or she does not obtain a professional or trade qualification—discrimination can take many forms (box 1). In medicine, there is also a requirement to register and an automatic loss of employment if a doctor's name is removed from the register. It is because of the crucial role of these organisations as a gateway to employment that the government has extended the Disability Discrimination Act to cover qualification bodies—such as the GMC—from October this year.1
The right to challenge in court
For doctors and medical students with disabilities this finally should mean protection by law. Heather Payne, associate dean for educational support in the Wales Postgraduate Deanery, explains: “Up until now, there has been no comeback on any educational body that excludes disabled people or fails to make reasonable adjustments. Now decisions can be challenged in court, and this will be the driver for some clearer thinking about what individuals have to offer to patient care and to the medical profession.”
She adds: “The Disability Rights Commission is supporting many test cases, and reports the results on their website. The damages awarded for failing to comply with the law are potentially enormous, so I'm sure that all those bodies will want to get it right.”
Box 1: Types of discrimination
Direct discrimination—this usually occurs when a qualifications body treats a disabled person less favourably simply because of their disability. This typically happens if a qualifications body makes stereotypical assumptions about a person's disability or its effects. Direct discrimination is never justifiable
Disability related discrimination—this is wider than direct discrimination and refers to situations when a qualifications body treats a disabled person less favourably for a reason that relates to the person's disability (rather than the disability itself). Disability related discrimination can be justified only if the reason for the treatment is both material to the circumstances of the particular case and substantial
Victimisation—this is a special form of discrimination directed at any person, disabled or not, who has brought proceedings under the Disability Discrimination Act against a qualifications body, or given evidence or information in connection with proceedings under the act
Harassment—this is unwanted conduct that has the purpose or effect of violating a disabled person's dignity, or creating an intimidating, hostile, degrading, humiliating, or offensive environment for that person. It can take the form of offensive actions or comments—written or verbal
Sitting on the fence
Currently, in accordance with the Medical Act 1983, the GMC Educational Committee can agree a modified period of preregistration house officer training for someone if they are affected by a lasting mental or physical condition. However, there are arguments for and against retaining this special provision, and the GMC has to yet to decide its position.
Clearly this has become a hot topic. In the recent government consultation document, Sharing the challenge,sharing the benefits: equality and diversity in the medical workforce,2 Sir Nigel Crisp, permanent secretary, Department of Health and NHS Executive, says, “Perhaps most complex of all for a profession dedicated to curing people, are questions of how the profession deals with disability and illness—whether it be in relation to students wishing to enter medical school, or the experiences of doctors suffering from stress and mental health problems. It's perhaps not surprising, therefore, a sense of injustice prevails among those members of the disabled community who wish to enter its elite.”
The document also points out that access to medicine for disabled students varies enormously between medical schools. Although education has been within the scope of the Disability Discrimination Act since 2001, the pending disability bill is likely to force the pace of change by placing further responsibility on employers to promote equal opportunities for disabled people. The taskforce urges all partner organisations to work to ensure they are ready to meet these legal requirements.
However, there are exemptions to the Disability Discrimination Act, as Heather Payne explains: “The `justification' of treating a disabled person less favourably may be supported by evidence [such as a risk assessment] if he or she cannot achieve the necessary competence standards, or the disability presents a health and safety risk to that person or others. But the standard applied must be the same as for everybody, and it must be realistically related to the essential work of the qualification.”
This part of the act has caused concern in some quarters about patients' safety and a fear that disabled doctors may overestimate their ability to perform certain skilled tasks.
Anne Tynan, author of the reports Pushing the Boat Out and The Sequel to Pushing the Boat Out, and project director of DIVERSE (www.ltsn-01.ac.uk/diverse/index_html/), agrees that concerns about patients' safety are legitimate, but believes that this does not apply only to disabled doctors: “Worries about `patients' safety' are justified—but to the same extent that worries about patients' safety have led to the introduction of appraisal and revalidation for all doctors. Risk assessments are a constant feature of health care, and therefore there should be no surprise that they are carried out. Appraisal and revalidation are systems that work to the benefit of disabled students and doctors because they should be able to provide more accurate information about when a doctor might pose a risk—as well as when he or she does not pose a risk.”
She continues, “Disabled students and doctors cannot be discriminated against on the grounds of a `presumed' risk to patients' safety. At the same time, disabled people cannot presume that `absence of risk' can be assessed without the disclosure of sufficient information. There must be a balanced approach on both sides.”
Box 2: Reasonable adjustments for qualification bodies:
Providing test papers in alternative formats such as large print or Braille
Allowing extra time in exams for someone with dyslexia
Allowing an assessment to be taken in a different way such as an oral as opposed to written exam
Providing a sign language interpreter for a deaf person at a meeting to review that person's registration
Box 3: Examples of adjustments
A medical student with dyslexia could reasonably expect to be given some more time in exams, or be able to type answers on a computer. But they would still need to display an equivalent level of knowledge to pass the written exam
A preregistration house officer might be unable to run to cardiac arrests owing to mobility problems caused by cerebral diplegia. It would be reasonable to agree that the doctor should join the crash team as soon as he or she could, and then take part in cardiopulmonary resuscitation and the resuscitation protocol
A senior house officer with recurrent low back pain after traumatic back injury could reasonably expect to be provided with clinic seating that would allow him or her to work in comfort, but would then have to be able to conduct an appropriate consultation
A surgical specialist registrar with rheumatoid arthritis might require extra time to complete training if sickness absence were needed, but he or she would still have to display operative competence and an adequate logbook
The Disability Discrimination Act does not require qualification bodies to adjust their competency standards, but they must make reasonable adjustments to enable disabled people to achieve these competencies (see boxes 2 and 3 for examples).
Peter Rubin, chair of the GMC's Education Committee, explains: “The act does not require bodies that award professional qualifications, like the GMC, to make adjustments to their competence standards, although they must be able to ensure that these standards are proportionate and not discriminatory. Essentially this means that the competence standards [learning outcomes] for medical students must be the same for everyone and must be appropriate in their aim of putting the safety of patients first. However, the methods of assessing or demonstrating those competencies can be subject to reasonable adjustments for disabled students.”
However, some are concerned about modifying exams that test competency. The concerns include the validity of an assessment if it's been modified, the ability to ensure equality of competencies, and the question whether, if the assessment method has been rearranged, it really the same competency that is being tested.
Box 4: Special Needs and Educational Discrimination Act 2001 (SENDA)
The act introduces the right for disabled students not to be discriminated against in education, training, and any services provided wholly or mainly for students, and for those enrolled on courses provided by “responsible bodies,” including further and higher education institutions and sixth form colleges.
If a disabled person is at a “substantial disadvantage” responsible bodies are required to take reasonable steps to prevent that disadvantage. These might include:
Changes to policies and practices
Changes to course requirements or work placements
Changes to the physical features of a building
The provision of interpreters or other support workers
The delivery of courses in alternative ways
The provision of material in other formats
What steps are reasonable all depends on the circumstances and will vary according to:
The type of services being provided
The nature of the institution or service and its size and resources
The effect of the disability on the individual disabled person or student
Some of the factors that might be taken into account are:
The financial resources available to the responsible body
The cost of taking a particular step
The extent to which it is practicable to take a particular step
Health and safety requirements
The relevant interests of other people
The final decision about what is reasonable will be decided by the courts.
Sam Leinster, dean of University of East Anglia Medical School, says: “Looking at competencies and at methods of assessments will inevitably mean a change to core competencies. I personally think we should make exceptions to fit individual circumstances rather than try to change things generically.”
Paul Dieppe, chair of Health Research Council for Disability Partnership and former dean of Bristol medical school, agrees that competency is key: “We have been in the mode of thinking that all doctors have got to be able to do all things. If you look at the breadth of things that you can do in medical practice you can free yourself up from all this nonsense thinking.” He believes more flexibility is required in the undergraduate training process: “At the moment medical students have to do everything and have to be good at everything. We would have to be prepared to say that some people don't do all of the course... andthatisa kind of anathema to the traditional way of medical training, where you all have to do everything and you all have to pass everything.”
Anne Tynan thinks that this needn't be the case. “There is no incompatibility between reasonable adjustments and competence standards. Once it has been established that competence standards are valid for a particular area of work, it is simply a question of building up experience of the range of adjustments which can reasonably be applied to them. This work is likely to take some years but will undoubtedly be achieved and lead to the entry of many more disabled people to health care.”
Anne has been working extensively with veterinary schools to improve the assessment means of disabled students. The DIVERSE scheme has drawn up a “competency matching exercise,” which is cited in the Department of Health's document.2 This examined the “essential day one competences” that are required of new veterinary surgeons and matched them up with various disabilities and coping strategies.
In November, representatives from the GMC and other professional bodies and qualifications bodies will participate in a DIVERSE conference on the theme of “Disabled People in Healthcare Practice: Time to Take Stock?”3
Anne explains, “Our approach fits in with the requirements of the Disability Discrimination Act and can also be applied to medicine, dentistry, and other areas of healthcare work. Colleagues from medical and dental schools have been involved in this exercise, as have individual disabled vets, doctors, and dentists.”
Who is responsible?
The medical profession is still unclear about where the responsibility for integrating disabled doctors ultimately lies. Sam Leinster says: “Previously, medical schools have said they can't admit someone because the GMC wouldn't register them. But this doesn't wash because if a student passes all their exams then the GMC has to register them. Really it's a case of nobody wanting to take responsibility.”
However, Peter Rubin is clearer who ultimately has the final say: “The education committee determines the learning outcomes that must have been achieved by a doctor at the time of graduation. These outcomes, which map on to Good Medical Practice, cover knowledge, skills, and attitudes and are set out in Tomorrow's Doctors for the undergraduate. These outcomes were developed following wide consultation. The outcomes are not discriminatory with respect to students with disabilities. Thus for the GMC the issue is not the health or disability status of a medical student, but their ability to achieve all the outcomes in Tomorrow's Doctors.
He continues, “Universities are responsible for selecting students into their medical schools and for providing a curriculum that will deliver the required learning outcomes. The medical schools have the responsibility to make sure that graduates are fit to practise. When a medical school awards a primary medical qualification, it is confirming to us that the graduate has completed in full a curriculum that meets our guidance and the requirements of the Medical Act.
Disability Rights Commission—www.drc-gb.org
SKILL—National Bureau for students with disabilities—www.skill.org.uk
Council of the Heads of Medical School—www.chms.ac.uk
“NHS Acute Trusts and Primary Care Trusts are responsible for making available the facilities necessary for the delivery of clinical elements of the curriculum.”
Medical schools are also under another legal obligation to disabled students in the Special Needs and Educational Discrimination Act 2002 (SENDA).4 The act introduces the right for disabled students not to be discriminated against in education, training, and any services provided wholly or mainly for students, and for those enrolled on courses provided by “responsible bodies,” including further and higher education institutions and sixth form colleges. The law also requires responsible bodies to anticipate the requirements of disabled people (see box 4). Heather Payne says: “It is for these bodies and the royal colleges to set out their stalls just now, and tell us about their plans for complying with the law and empowering disabled doctors and medical students. There are welcome signs of change in attitude towards disabled doctors, with greater access to buildings, exams, and course materials.”
She adds, “But there is still a long way to go, and it will be vital for our profession's senior and most respected doctors to lead the way in setting positive attitudes towards colleagues with a disability.”