Accommodating Students with Disabilities Enrolled in Medical and Health Science Programs

Tuesday, January 15, 2019

Transcript

Peter Berg

Thank you very much, Sadie, and again, welcome, everyone, to our first ADA Audio Conference session of 2019. We are happy that you have all decided to join us today. We've got a fantastic speaker and a topic that has drawn a lot of interest, so we are very happy about that.

The ADA Audio Conference Series is a project of the ADA National Network. The ADA National Network is funded by the U.S. Department of Health and Human Services, Administration on community living, National Institute on disability, independent living, and rehabilitation research. The ADA National Network is a leader in providing information on the Americans with Disabilities Act. You may always reach your regional ADA Center by calling 800-949-4232 or visiting the National network website, which is adata.org. There you can locate your regional office and get additional contact information for your center.

So again, we are pleased that you have all joined us today. As I mentioned, we have a fantastic speaker with us today. We have Lisa Meeks, who is an assistant professor at the University of Michigan Medical School within the Department of Family Medicine. Today's session is being recorded, and the audio archive will be available within 24 hours, and in about two weeks' time we will have an edited transcript also available for today's session. So the materials were provided ahead of time. Those materials, the handouts, along with additional resources that Lisa provided to us, will also be available when the session is archived. Again, that will be available in about 24 hours along with the material. So if you have colleagues that also have an interest in this topic and who were unable to participate live, again, this session will be available through the ada-audio.org website.

So I have done far too much talking, and at this point from an undisclosed location, I would like to introduce to you today's speaker, Lisa Meeks. Lisa, thanks for joining us.

Lisa Meeks

Thank you so much, Peter. Welcome. I understand there are almost 500 of you. I am so excited that there are so many people that are interested in this topic and that want to work towards greater access in health science programs.

I'd like to great lakes ADA Center and the National Network for the lovely invitation and for bringing this information to you and the stakeholders in health science programs. I think especially I am very grateful it's coming to you at no cost and in an accessible format.

So I am going to start on my acknowledgments slide, and I believe Peter or someone else are going to advance the slides for me. But I want to take just a moment to acknowledge my wonderful colleagues, Elisa Laird Metke and Dr. JAN Serrantino who often work with me on presentations. They helped develop parts of this presentation and generously allowed me to share them with you today. I want to direct you to two references that I am going to be referencing today.

Next slide. The first is the The Guide to Assisting Students with Disabilities: Equal Access in Health Science and Professional Education. I want to note that 100% of the royalties from this book and book sales go back to the Coalition for Disability Access and health science and education, whose mission is to develop, advance, and disseminate meeting practices and to facilitate access and opportunity for people with disabilities in health science education. This guide is an essential resource for anybody overseeing DS programs or practice in health science education, and it's available from the publish, Springer Publishing, and from Amazon. I just want to note this because the flow charts that are in your handouts come directly from this text.

Next slide.

The second resource that I want to bring to your attention is a recent report from the University of California San Francisco and the Association of American medical colleges, better known as the AAMC. This report is available for free in PDF, and we have a link there for you. And for $13, you can also purchase a bound version of this text through Amazon. This report highlights the research on inclusion in health sciences to date, given that's kind of an overview of the state of disability. And while it's grounded in medical education, I think the experiences shared by students and physicians and the considerations offered for improved practices are applicable to the wider health science education community. Remember, the 100-page reports -- 100 pages -- is available to you at no cost, and I think it's really helpful for programs. Most helpful is the appendix of considerations that are offered by domain. For example, specific to the DS provider, to your admissions staff, student affairs, faculty, et cetera.

Next slide, please.

So very quickly, our learning objectives today are to describe the federal mandates that guide reasonable accommodation decisions in health science programs; for you to be able to recite the process for determining accommodations in health science programs; to assess issues of undue burden and fundamental alteration; and to give examples of best practice and national norms for attendance-related accommodations, academic and program attic adjustments, and modifications at clinical settings. I am also going to talk to you at a very high level about some assistive technology that you may not be aware of.

Next slide.

So let's start with objective 1, describe the federal mandates that guide reasonable accommodation decisions in health science programs. If you go to the next slide, I know I have assumed that by virtue of the work that most of you do that you are intimately familiar with the ADA and Section 504. So I am just going to give you a very brief review. The ADA, of course, is a civil rights law, but its purpose is to make sure that individuals with disabilities have the same rights and opportunities as everyone else. That includes health science students. In this case, the right to an education. If a student is a qualified student for your program, then they would be covered under the ADA.

Section 504 of the Rehab Act of 1973 states that no other qualified person with a disability in the United States shall, solely by the reason of their disability, be denied the benefits of and excluded from participation in or be subjected to discrimination under any program or activity. So higher education institutions under this guidance are required to make their programs accessible. Again, to qualified students with disabilities. Much of what -- much of the way in which programs accomplish this is done through accommodations or structural changes.

Next slide. Objective 2, to recite the process for determining accommodations in health science programs. I am going to go into a lot of detail in this section for you because I think this is where most people find that they struggle. So let's go to the next slide. There are two questions, as there are for any program. To begin the process of requesting -- to responding to a request for accommodation, you must first ask yourself these two questions. First: Is there a disability in this context? So in your program, is there a disability? If yes, then you must engage in the interactive process to determine reasonable accommodations and to potentially remove barriers.

Next slide, please. The interactive process -- this is taken from a UCSF/AAMC report, and it highlights the interactive steps to determining accommodations. You'll notice that the first step in the process is to determine the essential functions of the program. That might not be what you would have gone to as a first step in the interactive process, but really, without that Foundation, we can't thoughtfully engage in this process. So ideally, this is not something that should be done in response to a student's request. Rather, it is something that should have been done in advance and should be readily available to the DS provider and others who are critical in this process.

I also want to draw your attention to number 6 on this interactive process wheel. So number 6 says once implemented, the program should review the effectiveness of the accommodation in removing the barrier. If ineffective, the program should enter back into the interactive process to review potential alternative accommodations.

In my experience -- and throughout this webinar, I will give you some tidbits from my experience -- this is where a lot of programs fail. Failure to follow up or failure to have a process for following up or reporting when an accommodation is ineffective. Loss of engagement in the interactive process. Remember, this process is interactive, and it's very intutive, so it should always be in motion.

Next slide, please. While the interactive process will inform what accommodations are possible, there are a few items that the DS provider will draw on to begin the process of looking at accommodations. A starting point, if you will. This includes the student interview. So students live multifaceted lives. Students with disability -- all students, but students with disability lead rich, multifaceted lives, and they need to navigate their world on a daily basis. They know what works best for them.

One of the things I find is DS providers don't engage students about their everyday navigation of the world and learning. I encourage providers to tuck to their students, find out how they remove barriers -- how the student removes barriers to everyday living, and take notes on how these might translate to a clinical environment.

Another source of information to determine where you might start with accommodations is documentation. And this is really important. The documentation of disability often comes with an assessment of functioning and recommendations for accommodations. But I want you to remember that while the student's provider may have the best interest of their client or their patient in mind, they are not an expert, necessarily -- some people are -- but overall, they are not necessarily an expert in health science education. The associated technical requirements for your program or the essential functions for your program. This is why the recommendations from providers are simply that, their recommendations. This does not mean that the institution has to comply with all these recommendations, especially if they are unreasonable.

With that being said, if the program is going to reject a recommended accommodation, they should have good cause for doing so and should document the reason and the process that they used to draw that conclusion. Most recommendations will be in line and reasonable, but again, when you are talking about a health science program, it's very likely that the person who is presenting the documentation is not familiar with all of the nuance that a health science program entails.

Finally, observation. Providers should not be sitting in their offices disengaged from the clinical environment. If you are a disability service provider -- and I am sorry at the beginning I did not say I refer to disability service providers or disability service counselors as DS providers. So just that global term. If you are a DS provider in a clinically based program, you should be on the ward. You should be observing students during their testing, during standardized patient encounters, often times called OSPEs, in sim labs, and in situational and simulation lessons.

It's really, really critical that a DS provider in health sciences has firsthand knowledge and observations of students in these settings. This will help spark more creativity and certainly will lend itself to a more informed decision-making process. So for you DS providers out there working with health science students, invite yourself into the clinic and onto the wards to observe what really occurs in this clinical setting. You will be very happy that you did.

Next slide, please.

Remember, you need to engage in the process. Here is another visual about making the steps more concrete. You will notice that the first and highest level is a qualified student requesting accommodation. To be qualified, the student must meet the academic and technical standards of your program. And we'll talk more about that in just a moment. In this schematic, the DS office engages with experts as needed. So what is an expert? Well, an expert could be a content-based person. So if you have a student requesting accommodation in med surge or surgery, you might converse with an expert that is a surgeon or the program director for surgery or the head nurse for med surge. The expert may also be a group of colleagues, so other DS providers in similarly situated health Skypes programs. So if you are working with a nursing student, you may want to contact five or six nursing schools in your area or across the country and find out how they work with students with disabilities to help inform your decision-making.

Another step in the process is to determine whether or not the accommodations identified in consultation with the experts and in consultation with your colleagues challenge the technical standards, the policies, or the learning outcomes of your program. Then you are going to look to determine whether or not this would jeopardize patient safety. We are going to talk about this in more detail in just a moment.

If you determine that the accommodation challenges an essential function, a technical standard, or puts patients in a safety risk, then you need to look at whether or not there's a different accommodation or an alternative that would work without the afore mentioned challenges to the program's integrity or to patient safety.

Okay. Next slide. As part of registering for this webinar, you are provided with a packet of information, and in that packet is a flow chart. I certainly don't expect that you will be able to distinguish all of the portions of the flow chart based on this slide, but I do want to note that the flow chart created by Elisa was taken from the guide and generously allowed to be shared by Springer. This is going to take you back to the first two questions we talked about, and it's what I use in training. Is there a disability? That is question number 1.

Next slide.

This flow chart, again, created by Elisa Laird Metke and shared by Springer publishing in the Guide is how we determine appropriate accommodations.

For those of you who fall victim to the assumption -- and I know none of you have ever had this happen to you, but sometimes people fall victim to the assumption that DS providers "rubber stamp" accommodations. You just approve whatever comes across your desk. In those instances, it is really helpful to share this flow chart with your leadership to help them understand the actual very nuanced and very interactive process that you must engage in to make a good determination.

I find that when DS providers go straight to an answer without going through the process, the integrity of the decision is less robust. I encourage all DS providers, regardless of what you believe the auth come will be, to go through the process. In fact, I think it's a great idea to document each step in this process as you make a determination and make a decision.

Next slide, please. So going back to step 1, does the verified disability substantially limit a major life activity that affects the student in the university setting?

It is possible to be a person with a disability who may face barriers but not that are specific in your setting.

Next slide, please.

Now, does the disability affect the student in the academic portion of your program? IE, the didactic portion? So this is the -- if you are a lecturer, it may be a classroom where the student is left to complete modules on their own. This is prior to the academic portion. And the answer is yes or no.

Next slide, please. These are taken directly from the flow chart so that you can follow along. We are just going to address them individually.

So the student requesting a standard accommodation? And I know that when I use this for training, people say, well, what is a standard accommodation? And these are accommodations that are vetted, that do not fundamentally alter the academic program that have been approved multiple times across multiple scenarios and are approved by your deans and your administrators. So this is a decision that you could make independent as a DS provider. This might include something like extra time for examinations or a reduced distraction location. Next slide.

So I, in an effort to simplify things, like to talk about accommodations as one of two letters. Letter A and A means it's A-OK. These are well-vetted, time-tested, and standard accommodations that are in practice throughout the country. In my opinion, failure to approve a what I would consider an A accommodation is not something that would be justifiable either in a complaint or in any litigation because this is a standard practice across the country, and you would be hard pressed to prove that it was unreasonable.

One example I have seen lately of an A-OK accommodation not being approved by medical schools or nursing schools is extra time on an exam, and those are standardized patient encounters. While I refer to them as OSCEs and other programs do, other programs have other names and acronyms for them. But this is something that has been a little disturbing to me that I have witnessed in the last several months of institutions calling and saying that their program has denied an accommodation on a standardized patient exam. That is not to say that extra time should be afforded globally and in every instance in an OSCI exam. However, there is a very detailed process that you must go through to determine whether or not accommodations are reasonable. Most standardized patient exams are broken into three sections: The prework, which is often referred to as door notes or prereading, where a student is reading a scenario about the patient they are about to receive and provide treatment for.

The second portion is broken down is when the student goes into the actual encounter with the patient. That is a distinct portion of the evaluative process that should be individually assessed for whether or not extra time is reasonable. It is also the portion of the process for which most programs have difficulty with. I think in most programs' situations, the argument is you will not get extra time in "the real world." It is very difficult to distinguish how much time a physician or a nurse or any healthcare provider is going to spend with a patient. In fact, in billing for patient encounters in the real world, there are often limited exams, extended exams, these are things that denote the need for time to engage with the patient on the patient's matters.

Within the provider matters, there is flexibility in how individuals process information and perform tasks. There's a range within how these occur. So not everyone who goes into a patient encounter will complete that encounter within 2.5 minutes, just as an example. Some people will complete it in 1.5 minutes. Some people will complete it in 3.5 minutes. So I would argue that there's a range of time -- not a huge range, but a range of time in which most people will be able to complete that encounter. And that's just part of a normal variation of human processing and performance.

With regard to disability, you have to take into account the discrete amount of time that might be needed based on someone's disability and whether or not that is reasonable. For example, if you have a student that has limited hand functioning and needs to use alternative mechanisms for completing his or her evaluation of the patient, it might take 30 more seconds to plug in an adaptive otoscope than it would for another student who is entering the room and using the otoscope that is equity loved on the wall. Your responsibility as a DS provider and your responsibility for those listening that are administrators and faculty is to ensure that the access to the curriculum is there for a student with a disability and that if there is a barrier to the access that that is accounted for in an appropriate accommodation, in this case it might be that 30 seconds of extra time.

The final section is what we call the write-up portion or the presentation. Since sometimes students will be doing an oral presentation of their findings, giving what they have reported, what they think the differential diagnosis is, and what their treatment plan is. Sometimes students are asked to write up these findings in a very brief but focused note on their findings and next steps.

For a person that uses assistive technology, it may be that using voice-to-text technology is essential for them to have full access to that latter part of the assessment. In this case, it might take more time because they might have to log in with a two-part authentication to use an adaptive piece of technology on a hospital computer. Again, this might be 30 seconds, it might be one minute. There is a really good article that was written by myself and someone else on the exam, and it helps DS providers break down the essential steps to determination of this type of accommodation, and I believe that is in your -- I also provided a list of recommended reading and other essential tips for DS providers, so I believe that is on that list.

Extra time may be a reasonable accommodation on an OSCE exam, and I think that it's really important that in an A-OK situation, something that is occurring nationwide -- and I assure you, most programs are accommodating their OSCE exams -- that you in your program not be the program that is not even engaging in the process but is halting it at the very beginning by saying something like we don't provide accommodations on standardized patient exams. Or something like we don't provide accommodations in clinical settings. There are multiple cases and OCR complaints that you can be directed to that would prove otherwise.

Okay. So in the case of the other letter or accommodation B, the B stands for better interact. So DS providers should definitely start the engagement of the interactive process with their administrators and other program authority figures. These accommodations may be novel, not just novel to the setting, but they may be novel in general. May be something that no one has ever done. I really enjoy the creativity part of this profession. And they may require the expertise of a healthcare professional to determine patient safety or whether an approach is equally efficacious for a patient. They may require an administrative or curricular input if there is a modification to the program. Or a faculty, a clinical faculty if the expression of the clinical skill is to be addressed in an alternative manner.

So let's go to the next slide. So again, B. A B accommodation could be, for example, deceleration of your program using modified approach to a procedure, showing a clinical competence in a simulation lab versus on the ward, or being excused from a significant amount of time in the program. These are all things that require a really robust, interactive process.

The question you would ask yourself -- next slide -- in a situation where you are looking at a B accommodation would be would the proposed accommodation result in a failure to meet any technical standards of the program? Remember, this only applies if your technical standards are not discriminatory and if they directly relate back to an essential standard for your practice or if the accrediting body requires that students have a specific experience. A really good case to look at would be -- I think it's Palmer Chiropractic v. Davenport Civil Rights Commission.

Next slide.

So with regard to technical standards, there must be a careful creation of the technical standards. I know that many of you programs out there are in the mix of rework -- in the midst of reworking your technical standards, amending them, bringing them into 2019, making sure that there is no discriminatory language in them, and that every single technical standard points to an essential function in your program, that you can make those links.

So the ADA says that schools shall not impose or apply eligibility criteria that screen out or tend to screen out an individual with a disability or any class of individuals with disabilities unless that criteria can be shown to be necessary for the provision of service, program, or activity being offered. So if you can show that someone that's entering your program absolutely must need this skill with or without accommodation, then that can be a technical standard. So this means that the technical standard must focus on the skill required. As an example -- and I use this example a lot -- some technical standards out there will say must have sufficient hearing to be able to hear a heartbeat or something of that nature. In reality, what you are actually measuring is the individual's ability to detect a heartbeat and detect whether or not it was normal or abnormal. That can be done through several mechanisms, and it can be done with just in hard-of-hearing nurses and physicians. So the ability to hear a heartbeat would be considered discriminatory language.

Next slide.

Having nondiscriminatory and meaningful technical standards is important. It is equally important to ensure that they get to the individuals who need them, people who are thinking about coming into your program, students who are in your program and find themselves at the juncture of a disability while in the program. So disseminating technical standards is really important, and what I recommend is that you include your technical standards on your website as part of the admissions information. Potential students should be made aware of the technical standards prior to applying to the program, and they should also be allowed to have a confidential inquiry into what disability accommodations are available. Once admission is offered, programs should again provide a copy of the technical standards, and they should ask all admitted students to sign a statement attesting that they can meet the standards with or without reasonable accommodations. Again, it is really important to have the information about who to contact in these situations available and included in your technical standards such that a student that had questions about their ability to meet these technical standards would be able to have a direct line to the person who engages everyone in that interactive process, and that would be the disability service provider in most programs.

Next slide. So the second of the four questions when you have a B accommodation that you will need to ask is: Would the accommodation legitimately jeopardize patient safety? Now, again, I am sure none of you have ever heard somebody being concerned about patient safety as just a generalized fear. That student has ADHD; therefore, what if they do not pay attention while they are on the ward; therefore, what if they give incorrect medication while they are on the ward; therefore, what if they cause a huge drop in blood pressure; therefore, what if they ... and so on and so on and so on. So we do this catastrophizing about patient safety that in most cases doesn't exist or that in most cases we have set up fail-saves so that anyone -- because we are all guilty of having more and less attention at different points in the day. I think some of this is mitigated by the amount of coffee that we have. But that you have set into motion safety checks that keep everyone from harming a patient.

Next slide, please.

So with regard to patient safety, there is regulation and code that helps us understand how to approach this and these questions. One, a disability accommodation is not required -- and this is out of the U.S. Code -- a disability accommodation is not required where it poses a direct threat to the health or safety of others. So this is great, and I have given you the reference right here.

What I will say is that most programs reference this when they fear that a student poses a risk. However -- next slide, please -- there are additional codes that we must take into consideration. And some that say a school must ensure that its safety requirements are based on actual risks, not on mere speculation, not on stereotype, not on generalization about a student with a disability.

Next slide. So to review this more fully -- and I have underlined areas where it is very, very important. In determining whether an individual poses a direct threat to the health or safety of others, each school must make an individualized assessment. So that's the first underline, individualized assessment -- based on reasonable judgment that relies on current medical knowledge. That's the second underline, current medical knowledge. Or on the best available objective evidence to ascertain: The nature, duration, and severity of the risk -- so those are three questions. That's the third underline -- that you will need to be able to answer when you are doing a patient safety assessment. Nature, duration, and severity of the risk. And the probability -- so that's the fourth underline -- the probability that the potential injury will actually occur. And then finally, whether reasonable modifications -- and that's the final underlined, reasonable modifications -- of a policy, practice, or procedure or the provision of auxiliary aids or services will mitigate the risk.

Now, I am in medicine, so I am decidedly med centric in my thinking, and I apologize for that.

In medicine, medical students have multiple fail-saves, if you will, multiple supervisors who oversee everything they do. It is unlikely that a student could cause extreme patient safety concerns at their level of training. A lot of the patient safety concerns that I see in litigation are at the GME level, which is graduate medical education, and that's where they do the bulk of their training that specializes them in one area. With that being said, in programs like nursing, physician's assistant, OTPT, there's a lot more engagement directly with the patient, and there is a lot more opportunity for a patient safety concern. What I absolutely implore you to do when you do have concerns about patient safety is to go back to this slide and make sure that you are addressing all of these areas so that if you make the determination to pull a student out of the ward based on the potential safety risk, that you have articulated in writing your reasons for that and the process that you went through to determine that there was enough of a risk that you felt it was warranted to pull them out.

Next slide, please.

So to summarize, patient safety concerns must be evaluated on an individual basis, they must be objective, the risks must be very, very bad and very, very likely, and there must be no suitable accommodations for mitigating those risks.

Next slide, please.

So when you are evaluating, ask yourself: How would we assess safety risk for a student that didn't have a disability? So imagine a scenario where you have a student who has the same behavior -- and I have this incredible boss who used to give all of us in the med Ed team the same advice, and it was keep it performance based. Behavior and performance based. And what she meant by that was what is the student doing exactly that you can write about that you can then act on? We cannot assume things. We cannot predict things. So if you had a student and they didn't have a disability -- so you take the kind of presumption of the disability or perhaps the stigma of the disability out of the equation -- what would your action be with regard to what is happening that is performance or behavior based?

And then ask yourself: How would OCR or a court view this? Schools may only evaluate whether a student is meeting the school's own requirements. Another thing I see from around the country is a lot of programs, especially in medicine, talk about well, they won't be able to do that in residency or in residency this might happen. You really have to keep it in the domain for which you are responsible and which you oversee. So making sure that a student's meeting your requirements, the requirements of your program, and do not concern yourself unnecessarily with what workplaces do require because that is under a different title of the ADA, and there is probably a lot more flexibility than most people realize. So if you are a nursing program worrying about how a nurse is going to practice is not really focused on how a nurse is going to learn. Those are two different things. And nurses, I think of every profession, have so many opportunities for practicing in so many different areas and in so many different ways that I almost never worry about a nurse with a disability because I feel like there's just a multitude of opportunities out there, and we know and we have evidence of nurses with disabilities and physicians with disabilities doing really well, quote unquote, in the real world, and not only performing well, but making incredible contributions to our workforce.

And then finally, keep it performance based.

Next slide, please. So remember that alternative methods of providing care can be just as safe, even if they are different from the traditional ways. In fact, we've seen a lot of innovation in medicine around this, and sometimes something that was created because of a disability winds up being the standard of practice for everyone because it's just a better way to either assess or do a procedure on a patient.

Alternative ways of providing care are regularly practiced in the real world. And disability accommodations will be required in the workplace as well as in school, and I am sorry it looks like that might have cut off in the PowerPoint when it was sent over, so the word that is missing from there is school.

All right. On to objective 3. Assessing issues of undue burden and fundamental alterations to the program. Next slide, please. I want to make sure we are on the right slide. It should be number 3, would the accommodation fundamentally alter the educational program? Is All right. Next slide, please.

Fundamental alterations. So you need to look at the syllabus and be very, very clear about what is being taught, how it's being measured, and what the essential learning is. Remember when I said in the UCSF AAMC interactive wheel, that step one was define your essential functions of your program. So for example, are you measuring skill? Are you measuring time to completion? Are you measuring professionalism? Are you measuring clinical knowledge? Are you measuring all of the above? Is it truly essential? Or is it simply historical? In other words, this is the way we've always done it; therefore, this is the way we continue to do it.

And can mastery of the material be demonstrated in another way? Remember, when you think about these -- how things should be done in advance of accommodation requests, when you understand what the essential functions are, that you will be ready to engage in that interactive process of very detailed information. This helps DS providers be thoughtful, it helps them be informed in their decision-making. So a syllabus should be provide for every course to the DS provider.

Next slide.

To give you a sense of what detailed means -- because it could mean different things for different people -- in talking about in a clinical setting, I am providing you with a link -- and I do have permission to share this -- to what I consider one of the best examples of detail that I have come across in my career. It is from Western University School of Medicine, and we will go into a little bit more detail about it, but of course I do also want to point out that each sill will I buy includes a statement about disability services and -- syllabi -- includes a statement about disability services and accommodations. Something else I highly recommend.

You can see they start out with the purpose of the rotation. The purpose of this rotation is to provide the student with a solid foundation in the diagnosis and management of common obstetric and gynecologic conditions as well as health care maintenance and disease prevention for women, regardless of what specialty the student may eventually pursue. In addition, the rotation should expose the student to a full breadth of clinical specialty of ob-gyn, so that any student specifically interested in women's health will be better prepared to decide if they want to pursue postgraduate training in obstetrics and gynecology.

Next slide. Here is more detail I copied and pasted from that syllabus. You will notice that the course has been divided or has divided the procedures into two categories, those that the student must do and those that the student must do or see in order to meet competency and receive credit for the clerkship.

If you have a student with fine motor deficits or rheumatological issues that, when flaring, makes motor activity difficult, you can go straight to the information about clinical procedures and determine if any accommodations are going to be needed for this student. You can see from the do category that a pelvic exam is required as well as slide preparation. So an OB exam is required of students. There are two items in the do column that may present an issue for your student. In this case, you might want to meet with the director to discuss alternative approaches to meeting this required clinical competency. An oral (?) or performing the skills on a high-fidelity mannequin may suffice, but this would be at the discretion of the program given that these are an essential function and an essential function stated in your program.

Say, for example, a student did not have a fine motor challenge but instead had issues with strength. They might be able to perform everything in the do column, but they might not be able or capable or they may fear doing the delivery of a baby for fear that their arm who are hand strength would not be there. Thankfully, delivering a baby is not an essential function of this clerkship, as outlined as it is listed under the do or see.

Assisting with a delivery, however, is in the do column, so now you need to drill down on the word "assisting" to determine how your student is best able to meet this requirement.

Okay. Step 4. Next slide, please. Would the proposed accommodation cause an undue burden on the school? And very sadly, I am going to say next slide, please.

I want to take a moment to apologize to the entire Alabama community for its recent loss. Roll tide, roll. I chose this slide when I thought that we were going to be national champions, and we are not. In fact, if you are listening, Clemson, congratulations. But here is where my Alabama comes out. If your school has one of these -- and what I mean by these is a national football program -- if you are part of the Big 10, remember that the entire budget of the university is assessed when making a claim of undue burden, including sports programs and endowments. If you know what football coaches make, you will know that there is money out there to cover accommodations.

Next slide, please.

So how does this translate to actual cases? In Argenyi v. Creighton in 2013, it was found that $200,000 to provide CART and interpreters was not burdensome, even though it was not a large university and it was a new medical school. In Featherstone v. Pacific Northwest University, even though the med school was only a year old, the court said it was not an undue burden to provide interpreters. When the school made the claim that there were no available interpreters in their city, the court deemed this claim incredulous, and that's straight out of the court findings.

Next slide, please.

In Searls v. Johns Hopkins, we see an employment case. So I just want to give you, as I said, there are accommodations that are required under the other title in employment. So I just want to give you the listener who maybe has to think about accommodations being applied to employment setting and having it lesson your burden of fear that your student will not be able to work, quote unquote, in the real world. You should know that a recent court case, 2016, was in regard to an interpreter that would need to be hired for a newly hired nurse. The salary of the interpreter was actually going to be more than what the nurse was going to be paid. The court said this is not an undue burden to provide an interpreter. In making that determination, the court looked at the entire operating budget of Johns Hopkins Hospital, which was $1.7 billion. I have underlining the "B" for clarity, billion dollars. So remember the ability to pay for an accommodation typically favors in endowments, entire university budgets, and sports revenue.

Next slide, please. Objective 4. Give examples of best practice and national norms for attendance-related accommodations, academic and program attic adjustments, and modifications at a clinical setting. This is the meat of why most of you are here, and we are running really great on time, so I am excited to be getting a lot of questions.

Next slide, please. Attendance and academic/program adjustments. I am going to cover some of the most common accommodations and at the same time offer insight into whether or not these have been considered reasonable nationwide. I do want you to remember that each case is different and each program maintains their own requirements, so every request should and must be reviewed in the context of your program and with regard to your student. Some of the accommodations I am going to talk about today may not be reasonable in your setting. That is going to require an individual assessment in that interactive process with your program.

Time and location. So first, to absences. Generally speaking, students must be able to attend all clinical activities. By virtue of the program being clinically based and requiring time on the ward, the ability to be there physically is paramount.

If a student must miss an occasional day or an occasional activity, those should likely be accommodated and students should be allowed to make those up. But generally speaking, students must be able to be there. This is important because not only are you on the wards and learning actively with patient care, but there are simulation exercises. There are small group activities. And anatomy labs, things of that nature that students must be able to engage in.

With regard to a leave, my personal opinion is that any student for any reason should be able to take a leave at any time to meet whatever need they are having in that moment. I hesitate to talk about leave of absence as an accommodation because, again, I feel like it should be available to all students. But in some cases my understanding is that to receive a leave of absence it must be an accommodation afforded to the disability service office. In those cases, I think that a standard of a long-term, one year, or short-term, perhaps one clerkship or one rotation, should be given. Right now, there's a lot going on in the country with regard to leaves of absence, and I know that myself and Dr. Joe Murray will be presenting at the Coalition Symposium on a case and giving some best practices with regard to leaves of absence coming this April.

With regard to breaks and relief, relief from clinic to attend appointments on a weekly basis has been done throughout the country in multiple different types of programs, and I believe if we are going to walk the talk of our wellness and mental health initiatives that we are ethically and morally obligated to relieve students to engage in these activities. I would have a very hard time defending someone not releasing their students to attend appointments that are imperative for their mental or physical health.

Breaks during the day may be necessary, depending on the disability, and those should be reasonable as well. I remember going from 6 a.m. to sometimes 10 p.m. and rarely having time to eat or go use the restroom, and you know, that's the life in a clinical setting, but I think that for some individuals with specific disabilities, it is critical to their health to be able to use the restroom on a, you know, somewhat scheduled routine to be able to sit and be off of their feet for ten minutes at a time, and I think that within reason, these are reasonable.

We also have hard stop at night. So as you know, there are opportunities for students to stay, depending on the rotation and the specialty. It may be that a student is at the hospital till midnight, 1:00 a.m., and for some students, especially students that have a history of mental health disabilities, those students may absolutely depend on getting eight hours of sleep to be able to fully function and maintain their mental health. As well, students that have autoimmune diseases are highly subject to flairs in instances where they have not been able to sleep for six to eight hours an evening. So having a hard stop at night may very well be a reasonable accommodation for a student with a disability. This is something that is happening not only at the undergraduate medical education level -- so medical school, nursing school, and others -- but it is also happening in residency or when nurses are on the wards. Even if they are doing shift work.

Then overnight call relief. What I have noticed is that only about 40% of programs actually make their students do overnight calls, and even within overnight call, it varies from program to program as to what that means. Sometimes it means that you are at home and you are sleeping unless you are called, and sometimes it means you stay at the hospital. So when I say release, I want to be very, very clear what my intentions are. This is not relief from overnight call with absolutely no duties to make up that particular portion of learning. What it means is that in lieu of overnight call, students with disabilities will, in many instances, do things like daytime call on a weekend or over a holiday, and this is something that needs to be scheduled far in advance of a clerkship to be able to communicate effectively and efficiently with all members of the team. This is, again, why it's important for a disability service provider to understand the essential requirements of every single course and clerkship.

So moving to the next column, scheduling, the location of clerkships, field placements, or clinical assignments may be adjusted as needed to account for disability accommodations and needs. Order of the clerkship or clinicals for programs that are not lockstep, so to all of you nursing programs out there who have this, you know, from zero to Master's Degree in nursing in eight months, put on your Super Woman cape because -- or Superman cape because we are headed that direction -- I understand you are in a lockstep program and sequence, and you are not able to rearrange the order of those clerkships, nor are you able to break in the middle of them. But for those of you who have clerkships or clinicals that are not dependent on the prior clerkship or clinical experience to inform those, so they can operate independently, it may be reasonable to reorder those clerkships to lessen the burden on a student with disabilities. And these may not be to remove the barrier to a student who is actively in a flair because of their disability, but rather, they may be preemtive to avoid a flair.

Let's go back to our student that has a mental health disability in nursing, has an autoimmune disease. So in those instances, the students perform better and feel better and are able to maintain their health when certain steps are in process. So when they get enough sleep. When they are not physically taxed. So in the case of somebody with an autoimmune disease. So in order To preemptively avoid a person from getting this flair -- you may be out of order with a graduation, so the best approach is to avoid this. It may be critical that that person is not doing surgery, medicine, and ob-gyn, three very physically taxing rotations, back to back. So in that particular example, it may be best to spread those out over the course of the year with one occurring at the beginning, one occurring in the middle, and one occurring at the end.

A reduced patient load. So while I have my own opinions about this, I will tell you that the national norm is that reduction in patient load is usually implemented for a discrete period of time for one of two purposes. One would be remedial. So the student has gone through the clerkship and they did not perform well. It was thought that they were overburdened with the patient load and perhaps learning some of the other technology, the EHR, et cetera, and therefore, they are in a remedial period, let's say two weeks, and in that remedial period, instead of having a patient panel of eight, they are going to carry a patient panel of four, or instead of four, they are going to carry a patient panel of two. So that's the first time that I have seen it done, and that seems very appropriate. Not necessarily accommodations based. It seems more like part of the remedial plan. Two, in a preemptive kind of ramp-up. For a student with a disability who requires multiple assistive technologies or who has another disability where there is concern that going straight into the clerkship and having all of the requirements of the clerkship loaded, quote unquote, onto them at once might not work well with their disability, that they need time to adjust. And in this case, I have seen this approach in two ways. One, I have seen the student go in early, so they ramp up through early entry into the clerkship, and so they would start a cycle with their peers with a full load at the starting point of that natural clerkship; however, they would go in a few weeks prior to that and start learning either the EHR, utilizing the assistive technology that you've developed for them for full access, something of that nature. And over the course of those two weeks, they would have a reduced patient load.

The other is for a student to start out the first two -- let's say two of an eight-week rotation -- to start the first two weeks with a reduced patient load but then make up that knowledge through working over the weekends to compensate for the lack of experience that they are receiving on the wards.

So decompressed clinical or academic schedule. This is occurring across the country, depending on the program and depending on what your requirements are. Some schools are -- the way that they have their curricular structure are a lot more flexible to be able to do this, while others are not. A lot of schools are moving towards longitudinal learning, and in that case, it may not be possible. But in cases where you have traditional block schedules, this would involve taking the third year of clerkship and sections it over -- sectioning it over two years. So essentially, the student is doing a block on, a block off, a block on, a block off. That's one iteration of the accommodation. The other iteration which I have seen is for the student to do, instead of eight weeks for, let's just say, pediatrics, they are doing 16 weeks for pediatrics, and this is a case where that reduced patient load may come into play, but they've extended that particular clerkship over more time. So two ways to handle a decompressed clinical or academic schedule.

The nuance of this is far more complicated than I can go into on a webinar, but I can assure you it's being done in multiple medical schools across the country, and so if you want more information on that, I could point you to schools that have done this and talk to you about how they have accomplished this. And I do want to say -- and I will speak for my experience, although it must be for other schools, I know for my experience it has worked really well, and I think all parties at the end of the day felt like it was worth the investment in the student, and the student was able to be highly successful, matched into a residency program, and do really well in residency, and this happened multiple times, so it's not just one.

So going down to extra time -- and speaking of time, I want to get through this really quickly so that we have time for questions -- course exams, online exams, quizzes, practical exams, OSCEs, standardized patient encounters, simulation or procedure labs. Each case may be a candidate for extra time, but these must be evaluated independently.

So I have an example case here, and I think it's worth going through. A nursing student has a flair of symptoms in the fifth week of a six-week med surge rotation. He is unable to finish the final week as he needs to seek care and stabilize his medication. The nursing program's first instinct is to fail the student because the policy says that students may only miss two clinical days in any rotation. So that's a policy of the program.

Next slide, please. Slide 51 just in case I might have forgotten to say that last time. So how can we determine reasonable absences? What are the core competencies of the course? Where's the procedural skills checklist? Is there an hours mandate? Where is the student on all of the above measures? For students who have completed or nearly completed most of the objectives, there may be a situation where the student is able to miss more than the time dictated by the policy. Remember, the policies can be adjusted, if reasonable, that they are open to the same accommodation requirements that everything else is.

Next slide. So assistive technology. You cannot offer that if you do not know.

Next slide. Modifications at a clinical setting. So I am going to go over several assistive technology devices, and I will go over them fairly quickly, and you can do more research on them. I have given you the name of each device. If that device would be helpful for you in a clinical setting.

So next slide. So mobility devices. I am infinitely surprised by the number of people who do not know that a standing wheelchair or a wheelchair in general can be used by not only a physician or a nurse but by a surgeon. I happen to be friends with several surgeons that use standing wheelchairs to perform surgery, and to me, it's just the norm. It just makes sense. But for those who don't know, this is part of a mobility accommodation whereby a student who has a cervical spine injury or other reasons for needing to utilize a wheelchair can actively engage in the process of patient care all the way through to surgery. There are chairs that are standing wheelchairs, so it allows the learner to stand and perform these functions. There are also chairs that are hydraulic and lift the learner to whatever level he or she needs to be at in order to perform the task or to meet with the patient.

Next slide.

Visual enhancement. There are multiple mechanisms for enhancing the field for a student with low vision. So some of those just include the addition of -- you can see on the right -- the addition of a magnification device that goes over a pair of laboratory glasses. It may also be that the student really would perform better using surgical loops. So surgeons will use loops that have high magnification when they are use doing things like neurosurgery. For a student with low vision, they may benefit from utilizing those loops, and loops also have lights that can be used, and so thereby being able to see what they need to see to perform a specific procedure.

Next slide. For bigger tasks, so not just, you know, provider-to-patient, student-to-patient, or student-to-doing a particular procedure in a lab or other setting, there are larger devices that can be used. Magnifiers do not have to be small. The magnifier on the left has a clamp that can be clamped to an anatomy table or an exam table or to a vet table to amplify vision for a low-vision learner. The magnifying device on the right is on a stand, and it could be kept in an exam room or at individual stations in an anatomy lab and could be easily moved and relocated as needed. There are also microscopes with built-in magnifiers and magnifiers that serve as jewelry. I actually wear one almost every day.

Finally, flat, inexpensive overlays can be purchased in multiple sizes and adjusted as needed.

So here is a tip for you. When you are looking for devices for individuals with low vision or individuals with inflammation in their hands, you can search for items that are earmarked for older adults with arthritis or low vision. A simple search on Google will yield lots of different options for modifying equipment, modifying an environment to allow a student to fully engage.

Next slide.

This is my favorite tool. I talk about it all the time. Cellscope, Welch Allyn give me no love. I think this is marvelous. What it is an otoscope that attaches to a cell phone. There are numerous disabilities that can be benefitted by the use of a cellscope. Somebody with limited hand functioning, the grip on your iPhone is large, and in most cases, these individuals are utilizing an iPhone already. It allows the person to distance themselves a little bit more and to position themselves a little bit more comfortably to be able to meet the needs of their patients.

For somebody that is color-blind, you can use this cellscope with an app added to it to be able to move objects that are being presented in color to high black-and-white resolution. For somebody that has low vision, you can use the cellscope, taking your fingers and placing them on your iPhone and widen, thereby magnifying what you are seeing on the iPhone. So lots and lots and lots of uses for a cellscope.

Same functionality with the Welch Allyn iExaminer that's an adapter for the Pan optic. So these are things that are just wonderful for use in clinical setting.

And I am getting an indication that it's almost time for questions, so I am going to really quickly go through the last few slides. If you go to the next one, there are some apps for color vision deficiency. As you know, there's a high number of CD presentations in males, so a lot of area medical students may have this. There are articles for you to reference in your handout.

Next slide. Text-to-speech technology. I think we are all very familiar with Dragon, but there's a new adaptation of the Apple Watch that allows students to record the patient interaction. I know what you are thinking, what are the HIPAA regulations around that. But there is an article that I have included in your handout by Clayton Luttrell at the University of San Francisco, and he adapted and I believe he talks about how they also addressed HIPAA compliance and EHR.

Next slide, please. For deaf and hard-of-hearing students, there are magnified stethoscopes, there are visual printouts for stethoscopes, and this is not new. You can look to -- in fact, I think I have them listed as a reference -- to Anthem, to find the best use of stethoscopes for a specific type of hearing loss.

And the next slide, attention deficit disorder or stimulation. I also included an article on that. But noise canceling headphones, checklists, and effective feedback are all mechanisms that have been used to support and accommodation students with disabilities that are intentionally based.

Finally for you, the Association of Medical Professionals with Hearing Loss, the Coalition, the Society of Healthcare Professionals with Disabilities, and I do want to very quickly give a shout-out to the University of Michigan -- go Blue -- to highlight their amazing campaign, #DocsWithDisabilities, that has just been -- it has been warmly welcomed throughout the entire world and is now used to share information about how to be more accessible in medical school setting. We were recently partnered with Massachusetts General Hospital, School for Health Professions, and they are doing the # nurses with disabilities campaign, so you can find both of those campaigns on Twitter.

And then we are ready for questions. >> PETER BERG: All right. Great. A quick update. Apologize, the supplemental materials are now posted, so if you can go back to your -- to the material page, you can access them now. If you can't get to them, they will be posted when the archive is posted of the session. I want to apologize for that. So the materials that Lisa -- the supplemental materials Lisa was mentioning are now available and will be available with the archive of the session.

So we've got a bunch of questions here, so let's dive right into them.

Very specific question -- >> Peter, can I say one thing? Very quickly, I am happy to answer as many questions as I can. I tend to answer questions that are super, super detailed -- I can't answer questions that are super, super detailed about a case. It would be unethical. I wouldn't know enough information. If we could keep the questions very global, that would be helpful.

Peter Berg

Sure, absolutely.

So first question, involving best practices of extended time or reduced distraction for anatomy exams that use cadavers, where students may have classes -- classes before and after the exam and where the cadavers may be available for a limited time.

Lisa Meeks

That is an excellent question, and I feel terrible that I didn't include that in my overview because that is such a difficult scenario for disability service providers. Great question.

So with regard to anatomy practicals, this has been handled a couple of different ways. I think the prevailing way is to take students with disabilities -- and as much as I hate grouping people -- to have them -- most anatomy labs cycle through groups of students because there are only so many stations that you can have, and you have more students than stations. So they cycle students through in groups. What I have done is have the students with disabilities that require extra time go through the cycle as the last group. Then after the last group has gone through, those students are able to cycle through again right away. So the first time they cycle through, they cycle through at the regular time. That way if you have a group that has students with disabilities and students without disabilities, you are still cycling them through in the manner in which everyone is being cycled through. Then the student with a disability -- when I run it, the students with a disability have to go through each station again with the discrete amount of time, so if it's time and a half, they are going to each station for another half amount of time. For practical purposes, there has been a shift in the practice at UCSF to allow the students with disabilities to have extra time to spend that time wherever they want, and so they can go to any cadaver or any microscope that they need to go to in that specific amount of time. So to be clearer, if the students have one hour in the entire anatomy exam and a student has time and a half, so they have an additional 30 minutes, the students with the disabilities would cycle through one time with other students. At the end of the day, when the last group is going. And then they would cycle through again for 30 minutes. Now, that is a very efficient way of doing it. It also protects the identity of the students with a disability because everyone is dismissed at the end of that last cycle, and then students with disabilities, there's a five-minute break in between, they come back and can cycle through.

If a student only requires extra time on -- say the student has CVD, so color vision deficiency, and they only require extra time on small structures or on the microscope portion, you could assign that extra time just to the microscope portion.

The other alternative is to have only students with disabilities cycle through as the last group and then to afford the time and a half in that -- within that cycle so that students have time and a half at each station.

Now, that is the most, I think that's the best way to do it without giving any student any advantage of having seen a station before or, you know, the other arguments that might be made. However, if you only have two students with a disability and you have to cycle through multiple students and you are cycling through 25 at a time, it may not be practical to do it that way.

So that is how I have handled this, two different ways handled the anatomy lab necissity for extra time.

Sorry, Peter. I do want to say you might get annoyed with me because at the end of each question, I will probably direct you to an article. There is an article about Neera Jain about practical exams, so anatomy exams, and for those of you who don't (?) compliance in higher education, it's a wonderful tool for disability service providers, and there is a coalition Corner article every month that comes out on a very specific topic to health science, and if you don't reef that publication -- for those of you in academic centers, you probably have access to it through your library, so if you just search Jain, NR are her initials, and anatomy exams or something of that nature, it should pop up, but it might also be on that list of resources for you. And that will tell you exactly what I have just told you but in greater detail and better.

Peter Berg

All right. Question about best practices or your experiences with students with disabilities who use service animals in clinical settings.

Lisa Meeks

Great. So the article on that is called CSPOT one, and it's in that same publication. And there is no best practice for service animals. They are able to be there. As we all know, there are two questions you can ask, and once you have done that, it's just a matter, to me, the biggest barrier is the relational barrier, the relationship with the hospital. And so reaching out to the person who is in charge of ADA accommodations at the hospital and partnering with them, getting them on board. It may be important to contact your legal just to also make sure that you have the backing of that individual, but students with disabilities who legitimately require a service animal, there should be no question. They are able to go into the wards. Now, there are areas of the hospital where they cannot go, and that is not defined by me or any best practice. It's defined by the CDC and in that article by Elisa Laird Metke, there is reference to the guidance that's given by all hospitals and patient care that's occurring where these animals can go.

So I can give you one example of a situation where on a specific floor there was one patient who was in isolation and another who wasn't. So when you are looking at assigning the patient panel, you would assign the patient panel where the animal can go versus where the animal cannot go so the student is still engaging in the learning process but it also able to have their animal.

I know there are several schools who have worked through this successfully, and would have much more detailed advice for you. I think if you start with that article, that's a great place to start, and then if you need to be connected to schools who have done it, I am happy to connect you with those individuals.

Peter Berg

Great. Next question. What does a college or university or program do when they are providing accommodations to a student and then the student is in a clinical setting and they won't allow or provide accommodations?

Lisa Meeks

Well, I think that -- that's a great question. That's just not allowed. So I think that one way -- I think education is the most important tool. I think it's the best way to have a conversation, to take the pressure off of it being an individual disagreement, so between the disability provider and the clinical setting or clinical site, and to make it into an us kind of discussion by saying, you know, I just want to make sure that you are aware of best practice, and there are certainly -- there are multiple webinars through the AAMC on this, this article today, multiple articles on it, guidance from the Coalition for Disability Access in Health Science and Medical Education, and presenting that in a kind way to the University administrator of the program or the hospital representative to say this is actually, you know, best practice that's informed by the law. And so if you are making a determination to say there cannot be a clinical accommodation in my program, first of all, you are wrong. I wouldn't say it that way, but I would say, you know, that that does not comport with best practice nationally, and that we may be putting ourselves at risk, not only are we putting ourselves at risk but more importantly, we are risking the success of our students who won't have access to what he or she needs. And I think, if you can present the conversation like that, student first -- because student support is absolutely the most important element. So never lead with the law, but student support first, and then scaffolding out with the law and best practice is usually effective enough.

When I find that people push back in a very global way like that, it's a lack of knowledge on their part. They just don't know any better. And I try to never fault people for not knowing what they don't know because there's a lot of stuff I don't know just because I don't know it because I am not in that space. And so we live and breathe in the disability space, and sometimes I think we have to pull ourselves out and remember that these are not bad people. They just don't know anything about what we do and about kind of what's happening across the country.

So if you can use that. If what you are talking about is a clinical site that you are affiliated with, there should be language in your affiliation agreements -- and this would be your contracts person, you can go through your legal counsel -- that states very clearly that accommodations are determined in your program, and they are implemented at the site, and that they agree to implement those at the site. Now, they should not have any cost associated with that, as you probably already know. But that should be in your affiliation agreement. Then when that is in place, you are able to really quickly go back to the affiliation agreement and say I understand you may not be aware of this or this may be completely new or you may never have worked with a student who needed accommodations before, so let me help you. I will show you -- I make myself available for anything that you want to discuss. I can give you some best practices that are in writing. For those of you who might get push back from faculty, as a research faculty member, I can tell you that for whatever reason the minute something gets published it is now golden. So sharing publications with your faculty I think is a great tool for education and for solidifying that this isn't just you and your department on your campus. This is the norm in the country and they are not aware of it yet.

Peter Berg

Great. We have time for one more question. We have a whole lot of questions unfortunately we are not going to get to because our time is running out here.

You talked about giving the example of the iPhone and a couple people submitted questions about the difference between necessary and appropriate accommodations that the school is responsible for versus personal use devices. How do you make that distinction?

Lisa Meeks

That's a great question. That's a great question. And it's something that I have not thought about, I think mostly because I am usually very highly focused on the disability part of it. But it would make sense that almost all of our students have an iPhone, so it would make sense that the technology and just the love of that technology might catapult a student into wanting to use this on the ward for themselves. I think that's probably more of a program decision about -- and hospital decision about what type of equipment is used. I know, for example, if you go to San Francisco, probably every pediatrician is using a cellscope. Why? Because you get a better visual field, you are able to make a better diagnosis, and that's better for the patient. But technology reins in San Francisco.

If you go at Michigan -- I will use that so I am not picking on anybody -- but our pediatricians may not be using the cellscope. One, they may not know it exists. Two, they may not see the need for it. It may be the bells and whistles type thing. They may feel that they are fully capable of making a diagnosis based on what they are able to see using the traditional otoscope.

I really think that's kind of the program has to lead what technology a student can bring in. There are also considerations with regard to patient privacy, and so normally when we utilize these devices as an accommodation, there are additional restrictions that are put on the individual's cell phone. So more encryption, things of that nature, that we work through with IT to make sure that while the student is utilizing his or her device that they are doing so in a really safe way, that they now have, you know -- or that they don't capture pictures. Because you can also with the cellscope capture pictures, send them to the EHR, second them for a second opinion. It's just beyond cool. But -- and as a reminder, I get no money from them -- but I think that certainly there are things that we have to be careful about when we are talking about personal electronic devices and their use.

With that being said, I don't know a student who is banned from using their cell phone in the ward. It may just be this they are not allowed to put the certain devices on to use as a tool for history and physical. That's a fantastic question.

Peter Berg

Thank you, Lisa, for all the great information. Again, apologize that we were not able to get to all the questions today. Again, you can reach out to your regional ADA Center. We will look to do something with the number of questions we have remaining.

Just as a reminder, our next session will be coming up on February 19. That session will be The ADA, Businesses and Barrier Removal: What are the Requirements?. You can get information about registering for that session at www.ada-audio.org. And as a reminder, today's session has been recorded. The archive will be made available, along with the supplemental materials. They will be posted, those materials, that Lisa had mentioned during her presentation, will be available with the archive of today's session along with the handouts.

So thank you again to Lisa. Thank you all for joining us today. We look forward to having you join us in the future. Take care, and good day.