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SPOTLIGHT: Thinking Differently

Students, schools and board exams contend with hidden disabilities

The New Physician March 2007
When Lisa Pappas addressed her "greatest challenge" in a medical school application essay, she wrote about the Medical College Admission Test (MCAT). The test undoubtedly is a challenge for most applicants, but it was particularly so for Pappas.

As an undergraduate at the University of Michigan, she struggled with a learning disability that made arithmetic and reading difficult. Because of this and an additional diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), the school provided accommodations for her test-taking. However, when it was time to take the MCAT, her request for extra time was denied. So Pappas devised her own strategy for taking the test, one that involved skimming the questions and 'skipping some of the reading. She explained this system in her essay.

During a subsequent admissions interview, one member of the panel went off the record. "I was specifically told I shouldn't have [revealed my disabilities in the essay], just because of the stigma," Pappas says. "It's not what they wanted to hear."

Pappas is now in the middle of a yearlong dermatology research fellowship between her third and fourth years at Wayne State University School of Medicine (WSU). At school, she requested and receives extra time and a semi-private room during exams. "I would have failed out if I hadnÕt [pursued accommodations]," she explains. "The thing is, I made sure only to ask for the things I really needed and not the things that might feel nice but aren't necessary."

Accommodation for all types of disabilities is related to 1990's Americans with Disabilities Act (ADA) and the earlier Rehabilitation Act of 1973. Among other stipulations, the laws mandate that educational institutions receiving federal funding cannot exclude students solely on the basis of their disabilities, and must accommodate disabilities within reasonable limits. Though the letter of the law is a bit vague, the courts have hashed out some of its meaning, and medical schools and their legal counsels have created departments and procedures for accommodating students' needs.

At most medical schools, students with learning disabilities or attention disorders must apply for accommodations. Medical schools need not-and generally do not-approach the student. Disability services departments consider a studentÕs application for accommodations and the documentation supplied by the student to support his or her claim, and then work with faculty to implement the accommodations. One of the department's considerations is how to stay within the purview of the school's own curriculum and standards.

"The purpose of accommodation is to level the playing fieldÉso [students with disabilities] are given the same opportunities to succeed or fail on their merits as anybody else," says Helene Horwitz, associate dean for student affairs at the University of Minnesota Medical School (UMMS). "I think sometimes students think the accommodation is there to help them pass, which is a little oversimplified."

Though Pappas had no trouble with her decision to pursue accommodations in undergraduate and medical school, she had resisted them in her early high-school years for one reason: "Pride. Because there is a stigma [about] asking for accommodations," she explains. "I didnÕt really want to go through it if I didnÕt have to."

Even now, she doesn't go out of her way to tell classmates about the extra time she is given on tests or the quieter classroom in which she takes them. "It is easier at a larger school," Pappas says, "because people say, 'Oh, I'll see you at the exam.' I would never say, 'Oh, I take it in a separate room,' unless I knew them really well."

"Students worry about that pretty frequently, and one of my jobs is to reassure them that no judgment will be given to them," says Robyn Gandy, ADA coordinator at the University of Toledo Health Science Campus in Ohio. "No one should be making commentsÑand that is the law." When accommodated students wonder what their classmates are going to say if they donÕt report to the exam room at the same time, she tells them that with two classrooms-worth of exam takers, hardly anyone would notice anyway. "I see the flip side, where their classmates are supportive and nurturing," she says.

In any event, Pappas hasn't felt any friction from classmates over her accommodations, but at times she has felt somehow marked. "I think it is more myself, how I felt, getting different treatment than other peopleÉ. The whole purpose of accommodations is to be on an equal footing. And so by telling other people that things are different, it makes you feel different."

But Pappas has had at least one conflict with a faculty member over her accommodations. A professor was reluctant to provide extra time at each station of an exam. When Pappas pressed him on the issue, he offered her more time after visiting all of the lab stations to finish up her answers. The solution wasn't helpful to her, but she didn't pursue the matter, instead taking the test without accommodation. It has so far been an isolated incident of resistance.

Otherwise, WSU has been great, she says, and a 3-year-old group there, the Student Team Enabling Peers (STEP), also lends support. Out of Pappas' class of around 250 students, about six take their exams in the same reduced-distraction setting. At first, however, they all sat at a single table. The STEP group convinced the school to provide individual desks instead. And the group, composed mostly of students receiving accommodations, provides a good place to vent.


The number of students applying for accommodations for learning disabilities and attention disorders is increasing, due in part to larger numbers of such students being accommodated through their undergraduate years, an increased awareness of their rights, and a somewhat more accepting environment in the often-competitive world of medical education.

Students with learning disabilities have become savvy consumers now, Gandy says. Through the ADA, people have become more familiar with learning disabilities and the need to accommodate students who have them. "If we go back 20 years ago," she says, "it wasn't common knowledge."

Broadly speaking, learning disabilities, distinct from attention disorders, are signaled by a significant difference between intelligence and achievement. Learning disabilities can include information processing and number problems, dyslexia and difficulties moving information from short-term to long-term memory.

Gandy says a standard deviation of two between the score on an intelligence test, such as Wechler's, against an achievement test, like the Nelson-Denny Reading Test, is her school's diagnostic standard for learning disabilities.

Attention disorders are not related to the processing of information, but to how well a student focuses on tasks, especially during tests and lectures. The University of Toledo looks at such instruments as the Connors Rating Scale and other such indicators, as well as self-reported symptoms and input from families and significant others.

But in order to be accommodated, students must first know where to go for help, and when. During orientation, Gandy administers a personality test to all new students and uses the opportunity to talk about the services her office provides, including accommodations applications. Her office also offers free tutoring to all students, up to 10 hours a week, and word-of-mouth brings students to her door.

"My name is very much out there, and faculty have been very supportive of my office," she says.

But the University of Toledo, like many schools, does not administer its own tests to gauge learning disabilities or attention disorders. Neither does Dartmouth Medical School, says Kalindi Trietley, director of learning and disability services there. To do so might be a conflict of interest, or at least be perceived as such. If there are ever questions about why a student did not receive a particular accommodation, the documentation would be from outside the school's walls.

At both Dartmouth and the University of Toledo, like many other schools, medical students must schedule and fund their own testing and documentation. When Trietley refers a student to a local counseling service for testing, the student can often recoup some of his or her costs from health insurance. Otherwise, students are free to seek documentation from any specialist meeting Dartmouth's criteria.

Gandy's office tries to put students on the right track if they suspect they may have an impairment. A cognitive psychologist by training, she used to administer such tests prior to joining the school's ADA compliance office.

"We try and look at other things that could be playing into poor academic performance," she says. She employs a preliminary screening tool that has proven to be fairly accurate before referring students to outside specialists for testing.

Medical schools tailor accommodations to a student's particular needs. Students with difficulty reading might get as much as twice the time on exams, to compensate for their impaired reading rate. A student with ADHD might be allowed to take tests in a distraction-reduced classroom, with just a handful of people. Otherwise, Gandy says, they might be in a room with 150 others.

Trietley grants students accommodations on a temporary basis. A committee composed of faculty members and legal counsel meets quarterly to review her arrangements and approve them. This gives the faculty a voice in how accommodations fit into Dartmouth's curriculum, and Trietley says this helps reduce their resistance to working with students who need to compensate for disabilities.


In Gandy's office at the University of Toledo, the heaviest traffic comes when the United States Medical Licensing Examination (USMLE) is on the horizon. A large number of students come in when the test is almost too close for accommodations to be approved by the National Board of Medical Examiners (NBME), which administers it.

If a student receives accommodations from the University of Toledo, his or her application for accommodations on the boards needs Gandy's signature. And some students who haven't previously sought accommodations-whether they've been using their own compensatory techniques to overcome their disability and stay below the radar or are panicking in the face of the boards-will show up with questions. Gandy suggests students start their USMLE accommodations process early, preferably in November for Step I, to get through all the paperwork.

At the NBME, an examinee's application is initially reviewed internally for completeness. If there's insufficient documentation, the applicant is sent a detailed letter to that effect. Once the NBME has all the documents it needs-formal letters from physicians, proof of previous accommodation in schools or on the boards, diagnostic test results-the consideration process can proceed, says Catherine Farmer, manager of the NBME's Disability Services department. At that point, most applications are reviewed by outside experts who consider the documentation and decide what accommodations to provide. Though applicants may request specific help, such as extra time or additional breaks over one or both days of the exam, the board has the final say on what students actually receive.

Receiving accommodations on Step I does not automatically mean accommodations will be granted on Step II, but it may simplify the approval process, Farmer says. If a student's disability waxes or wanes, for instance, some re-evaluation may be necessary.

Pappas was granted extra time and a reduced-distraction room for Step I. When she showed up on the first test day, however, the on-site proctor was reluctant to provide them. Pappas contacted the NBME, which she says was extremely helpful in seeing that the accommodations were implemented.

What makes the USMLE an important touchstone for students with learning disabilities, besides being the multiple-choice gateway to medicine, is that it's the point at which students' accommodations go on their records. For certain types of help, such as extra time, the NBME places an annotation on the test-taker's score report indicating that the test was taken under nonstandard conditions, Farmer says.


But the classroom and the clinic aren't the same, and accommodations that work in one may not in the other. And what is needed on a written exam might not be necessary in the patient exam room.

At UMMS, the process for deciding what accommodations students with learning disabilities need on the wards is the same as the classroom decision, but the accommodations can vary. The call schedule has been modified for some students, and the occasional student receives direct and explicit feedback forms, Horwitz says. UMMS has roughly five students per class receiving accommodations out of third- and fourth-year classes of about 220 students each. Her office also helps students with organization and time management-skills she says most students have to work to master.

Clinical faculty are informed of their role in a studentÕs approved accommodations by a chain of communication that spans UMMS' multiple training sites. "We have a series of guidelines, if you will: responsibilities on the part of the student, responsibilities on the part of the course director and responsibilities on the part of the director of clinical education," Horwitz says.

Though many clinical faculty havenÕt worked with a student who needs an accommodation, Horwitz says they tend to be fairly receptive. ÒAt this point in time, weÕve moved beyond [the attitude of] Ôeverybody ought to be able to do this.
Pete Thomson is associate editor at The New Physician.