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Substantial Frustrations


The New Physician December 2000
Zoe Gerard has known since the eighth grade that she wanted to be a physician. “From my preteens I’ve loved science and especially biology,” says Gerard, a third-year student at Mount Sinai School of Medicine in New York. “I thought about going into research, but it didn’t give me the immediate satisfaction or interaction with people that I love.”

While Gerard’s enthusiasm matches that of many of her medical school peers, one aspect of her self-definition sets her apart from the average student: “I was diagnosed in third grade with dyslexia,” she says. “I have made this part of my identity because I didn’t have any choice but to acknowledge it.”

By talking openly about her learning disability (LD), Gerard joins other medical students who admit that they process information differently from their peers and may need extra help with studying, test taking, and even, in some cases, clinical responsibilities. Others—who may or may not have been formally diagnosed with an LD—may recognize similar obstacles but fear disapproval from people who may not understand LDs (see “Defining LDs,” p. 14). “Disclosure was one of the toughest decisions I made,” Gerard says.

Because some LD students choose not to disclose and others remain undiagnosed, it is difficult to estimate how many medical students have learning disabilities. Dr. Larry Silver, president of the Learning Disabilities Association of America, estimates that between 10 percent and 15 percent of medical students are learning disabled. A U.S. Department of Education study identified 4.6 percent of medical students as having a disability of some kind.

So how does a learning-disabled medical student fare in today’s medical education system? It depends. For while medical schools are expanding efforts to help LD students achieve their potential, the National Board of Medical Examiners (NBME) applies strict criterion in determining which students qualify for medical licensing test accommodations under the Americans With Disabilities Act (ADA).

According to NBME rules, an applicant’s disability must satisfy the ADA definition of “substantially limiting” a major life activity. NBME applicants requesting accommodations are required to submit current and comprehensive documentation of their LD by qualified professionals.

These rules were recently affirmed when Michael Gonzales, a University of Michigan (UM) medical student, took the NBME to court. Gonzales, who had been diagnosed with a reading and writing impairment in 1994, requested the NBME allow him extra time to take the U.S. Medical Licensing Exam (USMLE). At UM, Gonzales had been allowed extra test-taking time, as he had at his undergraduate university. The NBME, however, denied Gonzales’ requests three times between 1998 and 1999, stating his learning disability did not “substantially” limit a major life activity.

After failing the USMLE twice, Gonzales, with UM’s encouragement, had a pro bono lawyer pursue his case. In August, a federal appeals court upheld a lower court’s ruling in favor of the NBME. The majority opinion stated, “Gonzales is not a member of the severely disadvantaged group Congress envisioned when it enacted the ADA.” Gonzales’ lawyer has requested a rehearing, and at press time the court had yet to make its decision.

Accommodations in Higher Education Under the Americans With Disabilities Act, which was published this year and co-edited by Shelby Keiser, manager of NBME’s Office of Test Accommodations, offers insight to the NBME’s decisions: “The ADA is a civil rights act, not an entitlement program….[and]…to be protected by the ADA, an individual must be disabled relative to the general population…. The intent of the law was to level the playing field, not to tilt it.”

So the message of the Gonzales v. NBME decision for LD medical students can be read as such: The players on this field are not one’s medical school peers but the general public. Thus what may be a substantial limitation for a medical student (i.e., a low score in reading comprehension when compared to other medical students) is not a substantial limitation when compared to the average person, whose abilities fall below those of most medical students.

Gonzales says he agrees with part of this interpretation. “My verbal IQ is higher than the average person’s,” he says. “But if the definition of a learning disability is the difference between your verbal and performance IQ, then I have a disability because my discrepancy is greater than the average American’s.”

Many view the NBME as effectively eliminating people with LDs from the medical profession. “The board thinks they’re a police organization that must crack down on people trying to cheat the system,” says Louis*, a first-year emergency medicine resident.

“People need to realize we don’t disclose just for fun,” says Gwen, a second-year student at a large Midwest medical school. “Nobody would hurt their chances of getting a residency just to get a little extra time if they didn’t really need it.”

Some schools seem to have awakened to students’ concerns. Brown University has “taken actions to free our students from being held hostage to the NBME,” says Dr. Stephen R. Smith, associate dean for medical education. When the board refused to grant accommodations to professionally diagnosed LD students, Brown decided its students no longer had to pass Step 2 of the USMLE in order to receive their medical degree. “The USLME…is designed as a ‘power’ exam in which the student can answer correctly only if he or she has the knowledge, regardless of the amount of time given,” Smith says.

By eliminating the USMLE Step 2 as a graduation requirement, Brown joins 29 other medical schools that require students to simply record a score on the exam. Another 22 schools do not require their students to take the USMLE.

Monitoring the situation is Medical College Admission Test (MCAT) director Ellen R. Julian, Ph.D. Admitting that the MCAT has a reputation of being less rigid than the NBME, she says accommodation requirements have been tightened. “Whenever you draw a hard line through a gray area, one side is heartbreak and the other is a ‘yes,’” she says. “It’s less of a judgment call now and more of a documentation trail.” One percent of MCAT applicants requests accommodations, she says. Around 34,000 prospective medical students took the exam in August.

“What [the NBME doesn’t] make clear,” Gerard says, “is that this is a difficult process with different criteria from the MCAT.” She received extra time for her MCAT but was denied accommodations on her USMLE Step 1. “[The] NBME called me a ‘compensating dyslexic,’” she says. Although Gerard did well on the exam, she found the experience emotionally and financially draining as she had to learn test-taking strategies to accommodate for her dyslexia while reviewing her first two years’ course work and spending $2,000 to recertify her LD evaluations.

NBME General Counsel Janet Carson is troubled by perceptions that the board is closing the gate on students with learning disabilities. “We have provided hundreds of accommodations to students with documented learning disabilities in recent years,” Carson says. “However, just because an individual is diagnosed with a condition does not mean his or her impairment rises to the level of ‘substantial limitation.’ Schools may use different criteria which says a diagnosis is adequate but Congress did not intend to cover everyone under the ADA.” The NBME says it doesn’t release exact figures on the number or percentage of applicants requesting or granted accommodations, because these figures are too easily misinterpreted.

But not all LD experts agree with the NBME’s interpretation of the ADA. “If medical students were functioning on that low [of] a level, it would be almost impossible to be a successful doctor,” says Barbara Guyer, Ph.D., director of Marshall University’s Medical H.E.L.P., a five-week program that aids LD students in overcoming their processing difficulties. “They are not competing with the average person in the street.”


LDs occur in individuals with IQs across the spectrum. The most severe are identified in elementary school. Others may not be diagnosed until course work overwhelms their coping skills.

“Each year we identified students who had not been previously diagnosed with learning disabilities,” says Dr. Harris Faigel, who has been director of student health services at Brandeis University for 22 years. “If you have an IQ above 130, it’s possible to develop compensatory strategies on your own. It may not be until medical school that you run up against your learning disability.”

An unexpectedly poor showing on the MCAT is often the first sign of a medical student’s LD. Many individuals are able to disguise their learning disabilities behind strong verbal and people skills.

“The typical person with a learning disability has what some call ‘gifts of greatness’ to help them compensate,” Guyer says. “They are usually more verbal, more creative and better able to relate to people—traits that can help them become outstanding physicians.”

Louis didn’t learn he had an LD until he applied to medical school. After an “abysmal experience” with the MCAT, Louis discovered he had an auditory and visual information-processing deficit. “Besides requiring that I take more time to learn, my learning disability affects testing situations,” he says. With extended time, he dramatically improved his score. “Admissions people thought the change was incredible, but the reason was simple. When people with learning disabilities receive accommodations, their scores improve.”


But it’s not so easy for medical schools to know where to draw the line in offering assistance to learning-disabled students.

“Because the NBME has taken a hard line, we have to be better informed [about learning disabilities],” says Dianne Cornelius, chair of the Association of American Medical Colleges’ committee that’s developing LD guidelines for student affairs professionals. “Schools must understand learning disabilities from philosophical, legal and practical standpoints,” she says. This means institutions must be aware of the various LD definitions and issues involved, the multiple guidelines for evaluating and documenting them, the financial considerations in providing accommodations, legal challenges and confidentiality concerns.

Cornelius, who’s also director of student and academic affairs at Michigan State University, says that schools also have to decide whether or not it’s worth allowing LD students extra time in medical school if it can lead to disappointment when accommodations are denied by the NBME.

Given these complications, many medical schools are reaching out in other ways to students with learning disabilities. A 1997 survey of 105 U.S. and Canadian medical schools revealed that 79 institutions were “strongly proactive in publicizing services or offering help to students with learning disabilities,” compared with 10 out of 103 institutions in a similar 1991 study, before the ADA went into effect. The most common accommodations were untimed tests and tutoring.

Medical schools often use the disability services available to all students. George Washington University School of Medicine’s (GW) procedure is typical. “When a student has—or is suspected of having—a learning disability, I send them to disability support,” says Rhonda Goldberg, GW’s assistant dean for student affairs and administration. At GW’s disability support, students receive a thorough screening and are sent for outside testing if a need for accommodations is suspected. GW, like many schools, then adapts the documentation guidelines prepared by the Association on Higher Education and Disability to its particular situation.

Determining who should receive accommodations is challenging. “Students must meet our criteria,” says Cyndi Jordan, Ed.D., disability coordinator for the University of Tennessee at Memphis. She sometimes grants accommodations based on previous documentation but advises students to obtain current evaluations, warning them that the older studies will not be accepted by the NBME. Jordan says she makes students “jump that hoop” so they aren’t surprised at the NBME’s strict criteria and fooled into thinking that it will automatically accept their request for accommodations.

In addition to offering accommodations, many schools teach study strategies that especially benefit those with LDs. Faculty members acknowledge varied learning styles by distributing lecture outlines and study sheets. Most medical schools provide notes, at least for first-year courses, and the State University of New York at Buffalo has gone one step further by videotaping lectures and demonstrations.

Researchers at Oregon Health Sciences University (OHSU) Center on Self-Determination are helping medical school faculty better assist their disabled students. With U.S. Department of Education funding, they have interviewed disabled students across the country, including those with LDs.

“Medical schools sometimes try to offer disability services with very little training on what is appropriate,” says Jared Schultz, project coordinator. The center offers workshops on disabilities and how to teach and accommodate disabled students to representatives of OHSU’s schools of medicine, nursing, dentistry and allied health, as well as medical programs at Portland Community College. The representatives then share this information with their colleagues.

A different approach is taken at the University of Minnesota, where medical programs had been referring students to disability services only when there were accommodation problems. “[But] we needed to be more proactive,” says Barb Bablock, an education specialist. To combat the perception that disability services did not understand medical curricula, Bablock met with curriculum committees to learn each program’s unique requirements.

“The campus climate is changing,” Bablock says. Medical students’ printed course schedules now include a statement at the top defining disabilities and inviting students to call Bablock. Disabled students have organized seminars to help their peers learn how to interact with disabled patients.

Despite such services, however, some students hesitate to reveal LDs. (Those taking their MCATs and boards with accommodations have no choice as a notation is made on their scores.) “I worry what might happen if I get that label,” says Ethan, a fourth-year student at an East Coast medical school. “With more physician information available to the public, could this end up on the Web? Would patients choose a physician with a learning disability?”


To thrive in medical school, students with LDs agree you must become your own advocate. Network with other students, and check out schools before applying to learn about their available services and their prevailing attitudes. Then use those services.

LD students also ask their peers to be proactive in their pursuit of medicine and learn about LDs before they go into medical practice, especially those pursuing pediatrics, neurology or psychiatry. “In my case,” says Max, a fourth-year student at an East Coast medical school, “red flags were ignored” by professionals who should know how to recognize them. He would like his peers to be better prepared.

“A learning disability is not a lack of intelligence,” Gerard says. “In fact, it shows a superior intelligence because you have been able to work with it. My recommendation is to learn about it, understand it and accept it as part of you.”
Peggy Ann Brown is a freelance writer/researcher based in Alexandria, Virginia.