People with physical or mental disabilities have disadvantages the rest of us can only imagine, and when it comes to the delivery of health care, the insult is compounded. Disabled patients have a harder time than other people in finding a doctor, and when they do, they receive inferior health care, less information about prevention and fewer screening tests.
According to a recent post on the NPR health blog, about 1 in 5 Americans has a physical or mental disability, and not even 1 in 5 U.S. medical schools teaches students how to talk with a disabled patient about his or her needs. In May, we blogged about a single-state study showing that disabled patients receive inferior care in many ways.
More than half of medical school deans say that their students aren't competent to treat people with disabilities, and about the same percentage of graduates agree. Agencies that accredit and license practitioners have no requirements for clinicians to demonstrate competence treating patients with disabilities.
Dr. Leana Wen, who wrote the NPR blog, is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. One day in the ER, eight patients had presented within minutes of each other. The junior resident, two interns and a medical student signed up for all of them … except the guy in his 20s complaining of back pain.
The middle-aged man with chest pain, the old woman with a broken wrist, the teenager with a sore throat all were seen. Len saw one medical student read the chart for the man with back pain, and replace it in the rack. Nurses avoided his room.
After 30 minutes, Wen assigned a team to care for him. The chosen nurse said, “"We drew the short straw here.” The resident said, "I already ordered labs and an X-ray. It's going to take too long to examine him, so let's just get this started."
The man wasn’t being difficult, he didn’t smell bad, he wasn’t drunk or contagious. He was in a wheelchair.
The reason for his disability was paralysis from the waist down, which had been his plight since a car accident five years earlier. He told Wen that he was used to waiting, to being the patient patient, because caregivers always avoided him.
As it turned out, his back pain was the result of a kidney infection, and his treatment amounted to being given an antibiotic.
Medical offices often have people who can interpret for patients who don’t speak English. Medical schools teach students about diseases so rare most will never see a case if they practice for 40 years. “Yet,” writes Wen, “there's been only halting progress in the care of tens of millions of Americans with disabilities.”
Per the Americans with Disabilities Act, it’s against the law to discriminate on the basis of disability; the act guarantees equal opportunities for individuals with disabilities in employment, transportation, public accommodations, state and local government services and telecommunications. But it doesn’t spell out that equal treatment in a medical setting is a disabled person’s civil right.
Medical professionals often deliver substandard care to the disabled because of mistaken assumptions; they’re often surprised, for example, to learn that they are obliged to discuss risks and benefits with patients who are cognitively impaired. Some are surprised to learn that they should ask a patient with a physical disability about sexual activity, just like they would anyone else.
In a study last year published in the Annals of Internal Medicine, researchers telephoned doctors' offices in four U.S. cities to make an appointment for a fake patient who was obese and used a wheelchair.
The study was fairly small — 256 practices representing endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology and psychiatry.
But more than 1 in 5 offices refused to see the patient for reasons including a lack of trained staff, a lack of equipment and/or personnel to help patients onto an examining table and lack of access to the building. The highest rate of refusal was among gynecology practices, at 44 in 100.
Some medical schools have pilot programs to teach students about patients with disabilities. Some schools encourage students to rotate through rehabilitation centers, and incorporate interdisciplinary learning with occupational and physical therapists.
That’s nice, but it’s a paltry effort to address a significant patient demographic. We agree with Wen: “Disabilities education needs to be a central part of medical training in the same way that learning to care for people from different cultural backgrounds is now.”