The Other Disparity: Doctors Lack Confidence Treating Patients With Disabilities

Coronavirus disease 2019 (COVID-19) has put a spotlight on the differences in quality of health care and outcomes among persons of color. But another disparity is getting attention: the need for better care for those with disabilities, as health systems remain unprepared to meet their needs some 30 years after passage of the Americans with Disabilities Act.

A survey reported this month in Health Affairs found that only 40.7% of physicians were very confident in their ability to give patients with a disability the same quality of care as other patients, and just 56.5% strongly agreed that they welcomed patients with disabilities to their practices. Nearly a fifth—18.1%--agreed that they health care system often treats patients with disabilities unfairly.

More troubling, the authors also found that physicians’ views of persons with disabilities were likely rooted in bias. Among the 714 US physicians who responded, 82.4% felt that people with a significant disability have worse quality of life than nondisabled people, feeding into what the authors called the “disability paradox,” in which health care workers, including physicians, see those with disabilities as having a poor quality of life, when more than half of those actually living with disabilities report their quality of life as good or excellent.

With more than 61 million Americans living with disabilities—and the ranks growing as the population ages—this seems like a problem that the medical community would address. And yet, the authors said, that’s not happening. “Medical schools generally do not include disability topics in their curricula,” they wrote, and training after licensing appears lacking as well.

Even research is sparse—the authors, led by Lisa I. Iezzoni, MD, MSc of Harvard Medical School’s Health Policy Research Center and Massachusetts General Hospital, said their survey appears to be the first of its kind. Iezzoni has studied these health outcomes of persons with disabilities for years, and was diagnosed with multiple sclerosis herself during medical school.

“That physicians have negative attitudes about patients with disability wasn’t surprising,” Iezzoni told the Harvard Gazette. “But the magnitude of physicians’ stigmatizing views was very disturbing.”

Results, the authors said, showed that “even physicians with more than 20 years of practice, who presumably should have extensive experience with this population, did not appear more likely to strongly welcome patients with disability into their practices.”

As it has for people in racial and ethnic minorities, the COVID-19 pandemic has exposed the shortcomings of the US health care system for those who must navigate it with a disability. The authors wrote, “As states promulgated crisis standards of care to guide decisions allocating scarce resources, such as tests, intensive care unit beds, and mechanical ventilators, some of these standards explicitly excluded people with disability.

The HHS Office of Civil Rights went so far as to warn early in the pandemic that “persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities.”

It’s not just the patients—it’s taken years for physicians with disabilities to receive accommodation, despite the ADA. Older physicians were trained before the law’s passage, and before there were limits on a trainee’s work week. In decades past, a medical school applicant likely would not disclose a disability.

A 2018 change required residency programs to accommodate those with disabilities to achieve accreditation, and this has likely led to more disclosure. Data published in November 2019 in JAMA shows between 2016 and 2019, the percentage of medical school students disclosing a disability rose from 2.7% to 4.6%.

Better education is key, Iezzoni and her co-authors say. “All levels of medical education should include more training about disability, including disability cultural competence and etiquette. Training that provides greater empathy about patients’ daily lives, such as house calls or standardized patients who have disability, might offer important insights.”