Medical students’ attitudes towards disability and support for disability in medicine

Abstract

Background: The number of medical students disclosing a disability is lower than the number of disabled doctors.

Aims: This study aimed to examine rates and types of disability in medical students, whether students disclosed this disability and their support needs, and, if not, possible reasons for non-disclosure.

Methods: This was a cross-sectional questionnaire study of all medical students registered at the University of Aberdeen in October 2007 (n = 944).

Results: Six percent of respondents considered they had a disability on application to medical school, but only 4% had disclosed this on admission. After reading the legal definition of disability, the percentage of respondents considering themselves as having a disability increased to 13%. Disabilities included: specific learning difficulties; mental health issues; sensory impairment; chronic illness; and mobility problems. Challenges to their studies due to disability were reported by nearly half of the disabled respondents but two-thirds had not sought support. Twelve percent reported experiencing discrimination due to their disability. Broader attitudes to disability indicated that many (75%) respondents believed some disabilities would prevent the study of medicine.

Conclusions: Non-disclosure of disability in medical students may be due to several factors including narrow definitions of disability and negative attitudes towards disability from the wider student body.

Background

Universities in the UK must comply with the Disability Discrimination Act (DDA) (HMSO 1995). The DDA defines a disabled person as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. The impairment must last, or be expected to last, at least 12 months (special rules apply for fluctuating conditions) (HMSO 1996) and can include long-term health problems such as diabetes and some mental health conditions. Other conditions (e.g., cancer) are included from diagnosis rather than from when impairment occurs.

Under the DDA, disabled students have the right to have ‘reasonable adjustments’ (HMSO 1995) made for them at university. These include altering physical features (stairs, doorways, etc), (HMSO 1995; Cohen & Hebert 2004a, 2004b) making adjustments to the format of teaching material (DRC 2007) (e.g., electronic handouts, large print), allowing students to use aids (e.g., amplified stethoscope, coloured glasses, scribe), or giving extra time in exams (DRC 2007). Universities have a responsibility to ensure that disabled students can access all areas of the teaching and learning environment. Moreover, students are not obliged to disclose disabilities as universities should anticipate need and make adjustments in anticipation of disabilities which commonly affect students (DRC 2007).

It seems reasonable to assume that, in order to anticipate the nature of ‘reasonable adjustments’, medical schools should know what percentage of students are disabled (as defined by the DDA), the nature of these disabilities, and what adjustments are necessary to support students.

Five per cent of all students in UK higher education disclose a disability (Scottish Executive National Statistics Publication 2006). There are no data available to indicate if this prevalence is similar across different subjects, or areas of study. This is low compared to the percentage of practising doctors who have disclosed a disability, at least a proportion of whom will have had a disability at the time of medical school (DeLisa and Thomas 2005). It may be that not all medical students disclose disability, possibly due to fear of discrimination, or not regarding themselves as disabled, or being apprehensive of the potential outcome of disclosure (Social Care Workforce Research Unit 2007). Such fears may not be misplaced. A study of doctors and medical students with disabilities or chronic illnesses found that most had experienced discrimination, lack of equal opportunities, or unhelpful attitudes from colleagues (BMA 1997; Mercer et al. 2003). A study of nursing, social work, and teaching students and practitioners (Social Care Workforce Research Unit 2007) found that, although the majority of respondents had disclosed information regarding their disability to their institution, many had done so only partly, or in a stepwise manner, and often this was due to necessity rather than by choice. Respondents in this study were more reluctant to disclose hidden disabilities, in particular mental health issues.

There is little literature on the attitudes of medical students or doctors towards disability at medical school, or towards disabled doctors in the workplace. Roberts et al. (2005) used focus groups to explore the attitudes of medical students, doctors, and the general public to doctors with disabilities. Their results highlighted that some disabilities were viewed negatively (e.g., mental health problems, disabilities affecting communication). Such negative attitudes towards medical students with disabilities may have implications for peer disclosure of disability (Social Care Workforce Research Unit 2007), the support given to disabled colleagues (as students or after registration as a doctor), managing one's own health issues, and/or attitudes to colleagues with health problems (Health Policy & Economic Research Unit 2007). Furthermore, there is little research into the impact of disability on the study or practice of medicine for the individual with the disability.

Calls for acceptable levels of disability for prospective medical students to be defined and debates about whether disabled medical students can achieve the necessary competencies to graduate (GMC 2008) may also influence whether or not medical students choose to disclose a disability.

The aims of this study were to obtain a snapshot of current rates and types of disability, whether students disclosed disabilities to the medical school on application, what particular difficulties disabled students have experienced, and what support they have obtained, or would value, and to identify wider student views on the inclusion of disabled medical students and doctors.

Table

Practice points

Medical students do not always disclose disability, particularly mental health problems. Students are more likely to disclose disability after reading the DDA definition. Problems reported by disabled students include difficulties with academic work, assessment, ward attachments, and attendance. Most disabled students had not sought support for clinical placements. Many students stated that some disabilities would preclude studying or practising medicine. Students reported experiencing negative attitudes and discrimination.

Methods

A questionnaire-based electronic survey was sent to all medical students registered at the School of Medicine, University of Aberdeen, in October 2007 (n = 944). The survey was attached to an email invitation explaining the purpose of the study, an assurance of anonymity, and the contact details of one of the researchers. The invitation explained that completion of the questionnaire would be regarded as consent to participate and for anonymised data to be published. Details of the student support services were also provided in the invitation, and students encouraged to contact the services if they had any concerns about disability or required support for a disability.

Email reminders were sent on days 3, 6, and 9 after the original invitation to participate in the study.

The content of the questionnaire was designed with reference to the DDA and by consensus among the researchers. A draft version of the survey was reviewed for clarity and sensitivity by medical educator colleagues not involved in this study.

The questionnaire contained three sections. The first section, consisting of forced choice questions, covered year of study, whether the respondents regarded themselves as having a disability or not, and, if yes, whether they disclosed it on admission to medical school. The second section outlined the DDA definition of disability and asked respondents if they met those criteria. If so, they were also asked about the nature of this disability, whether it affected any aspects of studying medicine, and about any support or discrimination they had received. Responses were sought via open text responses. The third section asked if any disabilities should preclude the study or practice of medicine, with views on the nature of these disabilities being requested as open text responses.

Data analysis was undertaken using SPSS for Windows v15. Descriptive statistics were used due to respondent numbers. Responses to open questions were independently analysed by two researchers using framework analysis to identify common themes (Ritchie and Spencer, in Bryman and Burgess 1994).

The North of Scotland Research Ethics Committee stated that ethics permission was not required for this project. However, in the interests of ethical quality assurance, care was taken to provide appropriate written information so students could make an informed decision to participate or not.

Results

Disabled students

Responses were received from 35% of students (328). Of these respondents, 25% (80) were in the first year of medical school, 23% (76) in the second year, 16% (51) in the third year, 18% (59) in the fourth year, 15% (48) in the fifth year, and 3% (9) were intercalating. Some students did not complete the entire questionnaire. In these cases, the total number of respondents to each question is given.

About 19 (6%) respondents considered they had a disability on application to medical school. Twelve of these respondents (4% of total respondents) had disclosed this on admission (Table 1).

Table 1.  Disabled students

Year	Number of respondents with disability on admission	Number of respondents with disability as per DDA
1st	3 (4%)	9 (11%)
2nd	6 (8%)	7 (9%)
3rd	3 (6%)	7 (14%)
4th	3 (5%)	6 (11%)
5th	4 (8%)	11 (23%)
BSc	0	2 (22%)

After reading the DDA definition of disability, a further 23 students agreed that they met the definition, giving an overall rate of 13% (42 students; see Table 1) of respondents reporting a disability. Further results are based on the responses from these 42 students.

Disabilities described by the students fell into five categories:

1. specific learning difficulties (e.g., dyslexia);

2. mental health issues (e.g., depression);

3. sensory impairment (e.g., hearing impairment);

4. chronic illness (e.g., type I diabetes, chronic fatigue syndrome);

5. mobility problems (e.g., due to arthritis or previous injury).

Those with mental health problems reported depression most commonly and some were not specific about their actual diagnosis. Students were more likely to report mental health problems and visual impairment in particular after reading the DDA definition of disability (Table 2). Some disabled students (n = 5) did not describe the nature of their disability.

Table 2.  Disabilities reported by students

Nature of disability	Number (%) of students on admission	Number (%) of students after reading DDA
Specific learning difficulties	7 (2.1%)	12 (3.7%)
Mental health issues	1 (0.3%)	8 (2.4%)
Sensory impairment	1 (0.3%)	6 (1.8%)
Chronic illness	3 (0.9%)	6 (1.8%)
Mobility problems	3 (0.9%)	5 (1.5%)

Specific problems with their medical studies reported by disabled students fell into six categories:

1. difficulties with attendance due to ill health or attending clinic appointments (described by 40% of students with disabilities);

2. difficulties with written work (note taking in lectures, written exams);

3. funding issues (transport, special diets);

4. poor concentration due to illness;

5. difficulties on ward attachments (pain on prolonged standing, difficulty interacting with patients, spelling of medical terms, hearing in a busy ward);

6. difficulty in anatomy/surgery (colour blindness, poor spatial awareness).

Respondents’ open comments illustrated these specific problems (Box 1).

Box 1.  Examples of specific problems experienced by disabled students

‘Standing for long periods in theatre, etc, is not only difficult but painful’.

Student with mobility problems

‘Finding it difficult to talk to people’.

Student with depression/anxiety

Forty-nine per cent (20/39) of disabled students reported one or more areas of the course to be challenging due to disability (Table 3), with different issues relevant to different types of disability.

Table 3.  Areas of difficulty experienced by disabled students.^a

	Number (per cent) of students with difficulty in specified area
Area of course	All disabled students	Learning difficulty	Mental health problems	Chronic illness	Sensory problems	Mobility problems
Group work	3 (15%)	0	2	0	1	0
OSCE	5 (25%)	2	2	1	0	0
MEQ papers	6 (30%)	4	1	0	0	1
EMQ papers	7 (35%)	5	1	0	0	1
Written assignments	8 (40%)	7	1	0	0	0
Lectures	10 (50%)	7	1	0	1	1
Ward teaching	12 (60%)	4	3	1	2	2

Note: ^aPlease note that many students reported more than one area of difficulty.

Two-thirds (28/42) of disabled students had not required, or sought, any support from the university. For those who had sought support from student support services, the support provided included arranging dyslexia assessments and extra time in exams, assisting in applications for disabled students’ allowance, and counselling.

For those students who had sought support from the medical school, the support provided was similar but also included NHS placements arranged in accessible locations. However, the majority (81%, 21/26) of disabled students, who were at a stage in the course where NHS placements had already been carried out, had not sought specific support for placements.

Students commented that, although they may have received extra time and support in university exams, this would not be the case in clinical work and postgraduate exams. Some students therefore felt that extra time was inappropriate, as limited time would be better preparation for work on qualification (Box 2).

Box 2.  Examples of support

‘Good support from student support services, from organising my diagnosis and helping me to gain materials and computer programmes to assist me to arranging extra time in exams and offering help with technique.’

Student with dyslexia

‘Courses arranged to suit my needs.’

Student with mental health problems

‘Often time is lacking to make allowance to help me and I feel the need to do extra work out of class and get help from peers, in this environment I think this should be the case as these are the challenges I will face upon graduation’.

Student with dyslexia

About 70% (16/23) of disabled students (19 students did not answer the question) reported that the support they had received was sufficient.

Suggestions for further support included: better access to lecture slides in advance of teaching; more information regarding whom to contact with issues related to disabilities; help with transport; or placements closer to campus (Box 3).

Box 3.  Potentially useful supports

‘A specific advisor which I could contact, I felt lost when I first arrived as I wasn’t sure who to contact as I did not understand the job titles in relation to the problems I was experiencing’.

Student with specific learning difficulties

‘The support now has been amazing but I wish it could have been like this when I was in second year (I approached different people in the faculty for help in second year)’.

Student with CFS and depression

About 12% (5/42) of disabled students identified in this survey said that they had experienced discrimination. Students described comments made by medical staff or other students who were not aware of their disability, which discouraged them from asking for help or disclosing their disability. Others described derogatory comments from medical staff regarding disability aids, and the assumption that, as young people, they were unlikely to have medical problems (Box 4).

Box 4.  Negative attitudes towards disability

‘Other students have commented on the disability I suffer from in a bad way – even before they knew I suffered from it’.

Student with specific learning difficulty

‘There are lots of people I would avoid telling about it because of things I have heard them say about people with mental illnesses’.

Student with depression

‘Assuming as a young man that I am unlikely to be in pain etc’.

Student with arthritis

Attitudes to disability

Seventy-five per cent (232/311) of respondents, both with and without disabilities, stated that some disabilities would prevent someone from studying medicine. Eighty per cent (237/296) of respondents stated that some disabilities would prevent someone from working as a doctor.

Fifty-eight per cent (166/288) responded that disabled students should have adjustments made to assessments. Fifty-seven per cent (167/294) of respondents agreed with the statement that students with disabilities could be allowed to graduate with limits on their registration if they were unable to complete certain areas of the course due to disability; 28% (81/294) were unsure; and 16% (46/294) disagreed.

Disabilities thought to prevent the work or study of medicine could be categorised into four different groups as shown in Table 4.

Table 4.  Disabilities which would prevent working as a doctor

Theme	Number of students mentioning this disability as preventing work as a doctor^a
Factors limiting ability to perform role of doctor
Communication difficulties
Speech	6
Communication	17
Sensory impairment
Visual impairment	69
Hearing impairment	37
Impaired mobility	30
Impaired motor skills/dexterity	23
General physical disability	19
Learning difficulties	36
Factors affecting patient safety
Blood-borne viruses	15
Mental illness	25
Factors affecting ability to complete course
Chronic medical conditions	10
Factors suggesting adverse effect on doctor	4

Note: ^aPlease note that many students reported more than one disability which could prevent work as a doctor.

Discussion

Four percent of participants in this study disclosed a disability on application to medical school. This is lower than the national figure of 5% of all students in higher education (Scottish Executive National Statistics Publication 2006). However, this survey identified that a further 2% of students who considered themselves to be disabled at the time of applying to medical school, did not disclose this at the time of application.

Furthermore, having read the DDA definition of disability, the proportion of students considering themselves to meet that definition of disability doubled to more than 13%. This suggests that the proportion of all disabled students (not only disabled medical students) may increase if students are made aware of the broad DDA definition of disability. Providing the DDA definition of disability on all higher education application forms, before asking applicants whether or not they are disabled, may provide more accurate figures on the rates and types of disability represented in the general student body and specific populations within that body. However, a number of students, particularly those with mental health problems, may still choose not to disclose until reassured that this will not lead to discrimination. Even then, some may still not disclose.

Many of the areas of difficulty reported by disabled students pertained to exams and written work. While it seems reasonable to expect medical schools to anticipate having students who will have these needs, and to adjust for them in anticipation, we are uncertain as to how some of the other support needs reported by our respondents could be met if not disclosed by the individual student. The guidance from the Council of Heads of Medical Schools (UK) (2005) is clear that students have a responsibility to disclose disabilities, stating that students who deliberately fail to disclose information regarding a disability that has an impact on their ability to practise medicine safely may be removed from the course. Disclosing information means students can be supported by making teaching and clinical staff aware of their needs.

The majority of medical students in our survey view some disabilities as precluding the study and practice of medicine. Nonetheless, limited registration and adjustments for students with disabilities (those unable to complete certain areas of the course due to disability) were considered options by approximately half our respondents.

Whilst our respondents’ assumptions about factors limiting ability may not be wholly accurate, particularly given that extent of disability was not explored, the areas of concern in terms of studying medicine and practising as a doctor may be reasonable. In particular, difficulty with communication and rapport, examination, mobility in the workplace (especially in emergencies), and ongoing learning were identified for medical students. Similar comments were made about practising as a doctor but, interestingly, the students also commented on work which could have an adverse effect on the underlying disability or illness, showing an awareness of the potential effects of working as a doctor.

Only some students mentioned the severity of illness or disability as a factor in whether individuals could undertake the course and function as doctors. Whilst the attitudes of students seem to change as they progress through the course, and this may be an effect of the questioning method, in general, respondents’ views on disability seemed rigid. It was also of interest that disabilities thought to preclude medical studies were some of the same disabilities reported by current students. This may reflect poor attitudes which are not being addressed and could potentially be detrimental to peers and patients. Moreover, it may reflect students’ attitudes to their own health and to how they might deal with any illness they develop in the future.

Respondents reported that they had experienced poor attitudes to students with mental health problems or specific learning difficulties from both medical staff and students. Students with longstanding health problems also reported feeling uncomfortable due to the assumption that medical students should be fit and healthy. These views may suggest that the findings from other professions which identified stigma, labelling, and discrimination are relevant concerns, may also apply to medicine (Social Care Workforce Research Unit 2007). This merits further investigation.

One possible explanation for negative attitudes to disability generally, and mental health problems in particular, is the ‘hidden curriculum’, “the set of influences that function at the level of organisational structure and culture” in an institution (Lempp and Seal 2004). It is well recognised that illness (and particularly mental illness) is seen as a weakness by the profession (Health Policy & Economic Research Unit 2007). Thus, the role modelling which occurs on clinical placements and prevalent attitudes observed on the wards may adversely influence students. This possibility requires further research.

To the best of our knowledge, this is the first study of the nature of disability, disclosure of disability, support received, and difficulties experienced in medical students with a disability. We acknowledge that this study is limited by the collection of data from only one medical school in the UK and the relatively low response rate. We believed that it was important to allow students privacy to complete the survey if desired, and therefore balanced this against the higher response rates which might have been achieved with other methods. Moreover, the response rate of just over one-third of students compares favourably to their responses to other local surveys sent out by email, suggesting that the focus of the questionnaire was important to many students. It is possible that selection bias occurred, with disabled students more likely than non-disabled students responding; however, although this would affect our disability rates, our data are consistent with census data, and our finding that the DDA definition increased numbers reporting disability stands.

We urge other medical schools to carry out similar surveys to explore if our findings are representative of UK medical schools. Our data also suggest the need to further explore attitudes to ill-health and disabilities amongst students and doctors. The insights offered by this study suggest the pending publication of GMC guidance on what is reasonable adjustment in medical schools is timely.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Sarah Miller

SARAH MILLER, MBChB, is a Clinical Teaching Fellow.

Sarah Ross

SARAH ROSS, MBChB, is a Clinical Lecturer in medicine and therapeutics with an interest in medical education.

Jennifer Cleland

JENNIFER CLELAND, BSc, PhD, MSc, D Clin Psychol, is a Clinical Senior Lecturer. She is Head of Medical Education Research and leads the Communication Skills strand for the MBChB course.