Transcript
Mike McKee
Thank you very much. Welcome everyone to the session. We had a whole host of questions that we did not get to during that session in January. And we have a number of questions in addition to that fwifn to us in advance by participants. As a reminder, this session is being recorded. We will post an archive in the session within 24 hours. For your information, the PowerPoint presentation that is being displayed will be posted when we archive the session and it's posted. The hand-out that was available for you to download prior to today's session, and the presentation being used for the sefmgts be aware that the hand-out will be available. The archive -- you will have access to it if you're in the webinar room, you can view it as our speakers present. For those of you -- our speakers will describe and explain everything and those hand-outs will be available when the archive is posted. The ADA audio conference 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 and community living, national institute on disability, independent living and rehabilitation research. You can locate the regional ADA center that serves your state by visiting ADA -- or by calling 1-800-949-4232. All right. Lisa, the questions were so great that we didn't get to last time and the questions that were submitted in advance of today's session, Lisa has reached out for some help and brought in with her a couple of colleagues that are going to introduce themselves in a moment here. As a reminder, she is with the University of Michigan. You can find her bio by visiting the ADA-audio.ORG and select the link for speakers and you can get Lisa's full bioon that page. You have questions and we have some information to share and I'm going to turn it over to Lisa at this time. Lisa. It is all yours.
LISA MEEKS
Great. Thank you so much. I'm so excited to be back with everyone today and I appreciate so much the questions that were submitted. I hope that we can give you the responses that you are looking for and mainly we really focused on giving you some resources so that you can find information to answer your questions but also information that will help you with a Meieriad of questions down the road. You will notice there are reference slides in between some of the Q & As. Those are for your benefit. We won't go over them. They are just articles or resources for your education. So all of you know me already because you were on the previous webinar and so I will not take up any more of your precious time. I want to have my colleagues who so graciously agreed to join me introduce themselves. Mike.
Mike McKee
Thank you, Lisa. Thank you for the honor and opportunity to join today. My name is Mike McKee. I'm an Assistant Professor, not quite an associate professor. I did get promoted but it won't be official until later. The other thing I wanted to mention Assistant Professor at the Department of family medicine and one of the key areas that we focus a lot on is on disability health. So we are very interested in clinical as well as educational community and also research areas on this topic. This is a topic dear to my heart. I'm on staff and have a bilateral sensor neurohearing loss and I have a program on my right side and use a hearing aid on my left side. So I do have a personal experience with this topic as well as also providing family medicine services for many different individuals, many of them with sensor neuro hearing loss as well as other sensory disabilities. I do have a number of projects that we focus on with disability health and I'll stop there and let Jan introduce herself.
Jan Serrantino Cox
Thanks, Mike. So hello, everyone, and I'm also excited to be able to join Lisa and Mike on this call. Currently I'm the President for the Coalition for Disability Access in the health science education and I'm also an independent consultant with a company. A little about my background. Most recently I was director for disability services at the University of California Irvine and my work focused on students with disabilities in the schools of nursing and pharmacy and medicine. And I also was a contributor to the coalition book guide to assisting students with disabilities. Equal access in health science education and focused on the chapters on accommodation. Just to say a little bit more about my background, I started off as a special education teacher back in 1989. And that -- and that was probably where some of my greatest experience came. But when I came to UCI as the director of disability services, I was really struck with how different it is working with students in the schools of nursing and medicine and other health sciences. I'm so glad we have this opportunity to look at your questions and give you some information so that you don't have to struggle through like I did. And I'll turn it back over to you, Lisa.
LISA MEEKS
Great. So let's get started. Mike.
Mike McKee
I will be reviewing most of these questions and Lisa and Jan will be doing most of the discussions. But there will be certain areas where I'll jump in. So with that being said, the first question that we received was are there any accommodations specific for people with developmental disabilities? Mainly for individuals with high-functioning autism? Lisa?
LISA MEEKS
So we'll go to the next slide and I'll take that one, Mike. So when we look at individuals who are on the autism spectrum we can't specifically say that there are accommodations or barriers that they're automatically going to experience. But there has been a good deal of research on some of the top barriers. And so I want to go through a few of those. Executive function and lack of cognitive flexibility. I'm sure you're well aware of executive functioning. Deficits, things like time management, organizational skills but lack of cognitive flexibility is more on the ability to transition or switch from one concept to another. And we know that many students on the autism spectrum are not very quick in making that quick adjustment or transition. So that's one big barrier.
Another one is that many of these students on the spectrum are not comfortable or they fail to seek out help when they need it, or they -- or even accepting help when it's offered. And so pre-planning with students and getting good feedback from them is really important to identify if this is one of the barriers. Also if you have worked with students on the spectrum, you know that frequently faculty are sometimes uncomfortable. They pick up right away that the student is awkward and may be socially different than my students. A lot of times they see students as on the spectrum as being condescending towards them or even aggressive. And these are areas that students on the spectrum really don't recognize about themselves. So it can really create a huge wall between them and their supervisors or them an their peers. Of course, the awkward interactions with patients is also another barrier that students might experience. And it's really helpful to have accommodations to -- or training in working in alleviating that. And finally, probably the one that is most relevant is that students on the spectrum don't pick up those social norms and those unwritten rules, much like many students with ADHD as well. That they are not picking up things in inference and they don't adhere to the norms and courtesies and unwritten rules that the rest of us follow almost without thinking.
Next slide. So if you know me, you'll hear me go back to the core competencies and technical standards. I think it's important, I'll start here with the accommodations. It is important for you to understand what your technical standards say and what the core competencies say about professionalism, communication and behavior. This is an excellent tool to use when sitting down with students on the autism spectrum to make them aware of the expectations that one would have. For example in the domain -- these are just taken from randomly from health science school. But in the domain of professionalism this reads students should maintain and display ethical and moral behaviors commiserate with the role of physicians. The students expected to understand the legal and technical aspects of function within the law and ethical standards within the medical profession. If you have a student on the spectrum for disagrees with a protocol or a specific procedure, that is a hospital-based procedure and it is partially guided by the law or professional associations, this is one way to bring them back to the point of professionalism.
Reviewing the student code of conduct and the communication of professionalism domain helps. It helps when you are in the moment with the student. When the student maybe has had a mishap but also really helpful for those of you who know you're working with a student on the spectrum to address these things in advance with the student. So another way to look at this is to bring the student in and do some self-awareness assessment. Does the student have self-awareness of their behaviors or their interactions with people? Review those professionalism standards and competencies. This is another great way to work with students on the autism spectrum would be to review a clinical skills exam as a model of patient interaction. So all health science programs perform clinical skills exams and the majority of those health science programs, regardless of the program, actually videotape these interactions so that they can, one, assess them, and two, go back and work with the student if necessary. It would be really helpful if you were to identify a clinical exam that was an exemplar of a student interacting with a patient. And then to put side-by-side the exemplar video and the actual student who is on the spectrum. Their video and to walk them through step-by-step pointing out the areas that were difficult for the student.
Another approach is to remediate clinical exams or clinical skills in a simulation labor withstand ardized patients. SPs standing in for a patient. In this scenario you might work with a student on his or her interpersonal skills with patients and then go back and assess these through another standardized patient exam or to actually run the remediation. So helping the student perfect their skills with an actual SP. Something that's really important for students on the spectrum is to have a realtime feedback. When a student on the spectrum does a clinical skills exam and doesn't get feedback in two weeks it is not helpful. So working with the student and giving realtime vaoed back is super important. You can also work with a vocal coach or simulation center director. These individuals have specialized skills usually in acting or articulation. As you know so often students on the spectrum may have difficulty in kind of the way they talk if it's very monotone. And they can work with a vocal coach or director on improving the information as they interact with patients. Near peer coaching. What I mean by that is to take someone who is advanced in your program and a student that does really well in patient interaction and have them serve as the standardized patient and give the feedback to the student who is struggling.
Another potential accommodation or intervention is to take the student to the clinical site in advance of them being -- starting the rotation there or starting the clerkship there and have them orient to both the clinical sites and the electronic health records. Again, individuals on the spectrum have difficulty with change as Jan pointed out and so this may be a mechanism for reducing kind of the newness of the site location and the electronic health records.
Practice presenting rounds. Even disability service providers can practice presenting rounds with a student on the spectrum. You don't have to be a nurse or PT or physician to be able to do this. You can actually ask your simulation center for some retired cases and then you can work with the student on those facial expressions, into nation, things of that nature. Developing a bad that has an outline of how you -- it's highly effective. You would just make a print-out of the order in which you would report or present a patient and then you would reduce it to the size of the name badge the student wears every day and attach it to the same type of holder that the student already uses for their name badge. Students on the spectrum may also benefit from a reduced number of patients on the ward for a limited time. So what you are doing in essence is ramping up the patient load. The students on the spectrum, the patient panel is normally five for a student on a particular ward. You may start out with three patients and have the student work and get comfortable with those three patients in the first week, add a fourth patient in the second week and ramp up to the fifth patient. I know what all of you are thinking. That sounds great but these students have to do the same amount of patient care as others. That is easily remedied by having the student actually rotate perhaps on a Saturday or Sunday and see one or two patients on those days to make up for the clinical interaction that is lost in reducing their patient load during the week.
Noise canceling headphones are also really beneficial for students on the spectrum to wear as in down time. A lot of times that your down time when they're charting their patient or in between patient care or waiting for lab results to come in and being able to wear these noise canceling headphones is beneficial in reducing the amount of sensory stimulation that a student is experiencing during the day. We already talked about in VIVO feedback in a simulated session but also effective in a real world setting. Having a coach, precept tore or life coach or ADA coach. You can find individuals that work with the ADHD population that can also be helpful for students on the spectrum and having someone follow the student for a portion of the day and give real world feedback. For any of you have that worked with students on the spectrum you know how critical that feedback is to correcting behavior.
Video modeling. That's what we talked about in the simulation, to put up a video model of the student on the spectrum side-by-side with an exemplar student. I would advise you the choose a student that is not in the same class as the student on the spectrum or within a year or two. You want to draw from someone that is historical so that student doesn't feel like they're being compared to a real life peer. And then minimizing switching clerkship sites. This has been really helpful for me. I think the two most helpful things for me when working with medical students on the spectrum has been to have that in-VIVO feedback and minimize switching clerkship sites. Sit watt students at a hospital or clinical site and keep them there for as many rotations as you possibly can. They become acclimated with the environment and used to working within the system and helps alleviate the external noise that can be detrimental to a student. I'll turn it over to January.
Jan Serrantino Cox
Thanks, Lisa, we'll go to the next slide. Let's talk about additional accommodations. Having an assigned mentor that meets with the student once a week can be really helpful especially if you don't have a life coach or executive coach to work with the student. This person can help to review feedback that the student has been getting. Work on things like social norms or role play. I know that many students are hiring executive coaches to work with them on some of the higher skills, and that's also something to be considered. But definitely a mentor can help with the hidden curriculum and be direct about the expectations that are in those core competencies. They can also provide scripts. You can provide scripts for addressing when you are addressing their attendings or other residents. And definitely getting that feedback in writing is so helpful. In my experience, students on the spectrum really memorialize things so much better when they see them in writing. So when you give feedback or when students are getting feedback on the Wards, do it in writing. Make sure you correlate it back to the clinical competencies, and measures where they may not be -- they may not be so successful. And then again pointing out any new information that is coming in regards to feedback of any deficits, and then providing some good examples, some clear examples of how they could remediate. Whether it's through video modeling or taking notes on how someone else is doing that type of procedure or presentation. And then a final possibility for an accommodation is allowing the student to have a little bit of release time from the Wards so that they can keep on top of their own health and wellness. Next slide, please.
Lisa, I think that's you.
LISA MEEKS
Sorry. This is a sample badge. I talked to you earlier about making a badge for presenting patients and having it attached to the name badge. This would be an example of what one might look like. This says key features of presentation, opening one-liner describe who is patient is, number of days in hospital and main clinical issues. 24-hour events and then it goes on to work through the way that you would present a patient. The caveat to this I would say is that different attendings and different nurse manageers and different preceptors might want the patient reported out differently. Again working with the student as you rotate through the clerkships rotations to make sure the sample badge is in line with what the particular preceptor is looking for. And then I think also Jan did a great job of talking about how when you are working with individuals on the spectrum it is really important to have visuals. So whether it's the student is not meeting a clinical competency to have that in writing to show them exactly which competency they aren't meeting but also -- this goes back to the kind of condescendingness we hear so much about. The student corrects the faculty member. Is help the student understand an abstract concept like a hierarchy.
When you make rules for individuals on the spectrum they the end to follow them and understand and at least adopt them and follow them. This is just a visual that shows how medical students are kind of at the bottom of the barrel when it comes to hierarchy and how it goes up to interns and junior residents and senior residents and so forth. Just helping the student understand where they lie on the hierarchy and developing some sort of social rule about correcting individuals and how important that is. So I know we spent a lot of time on that one question. We won't spend quite as much time on each question but I know from personal experience that I get a lot of emails and Jan gets a lot of emails around working with students on the autism spectrum so we really wanted to take a deeper dive into that. For those of you who subscribe to disability compliance for higher education, there is an article in there written by a student on the spectrum and so that's a great resource for you. The next question.
Mike McKee
Before we go to the next question I always wanted to highlight that this topic is very pertinent to other students who have different types of disabilities, not just with the autism spectrum disorder. So personally for me I know Jan and Lisa mentioned a couple strategies that were very useful for me. I was reviewing critical skills, doing the mock video modeling is helpful especially as you incorporate an interpreter or another person that can help with any communication and the big thing is remediating many clinical skills. For me it was practicing with an amplified stethoscope with an assigned faculty member. These are very overlapping themes and strategies that can help a number of people.
LISA MEEKS
Very helpful, Mike. We had a speaker at our annual symposium, and he is a deaf physician and he talked about how some of the same things that might be barriers for individuals on the spectrum could be barriers for individuals that are deaf or hard of hearing because they're spending so much cognitive energy trying to attend to either an interpreter or captioner and sometimes if they're not hearing everything, things get lost in translation. So it may come off as a social deficit when it is kind of a secondary deficit to the primary disability of not being able to hear everything or not being able to pick up on the change in into nation of somebody's voice. I think that's a really good point. Thank you.
Mike McKee
Thank you very much. So we're going to go onto the next question. And the second one we have is are medical licensing boards held to the same standards? Specifically, some medical schools accommodate disabilities under the ADA only to have the medical boards deny them. How is this possible?
LISA MEEKS
Great question. And we'll try not to go too much in the weeds. I'm going to share with you -- this is a brand-new site I've not talked about this. Thank you for whoever submitted the question. I want to point out kind of what I see as the top issues that result in a denial. We actually, you know, counter to the assumption that the medical boards turn down a lot of students, we have actually -- Jan and I both have had a high success rate. I think my success rate was 98 point something percent of getting accommodation and Jan's was almost equally as high. When we're approached about someone who did not get accommodations there are a few themes that emerge. Failure to follow directions. So oftentimes we see students who submit a form and they have not followed the directions.
A good example is students in medicine and I'm going to defer to medicine. We don't are have a lot of issues with some other boards. They do a good job accommodating and approving students. So I'll just talk about the medical board for now. This is applicable certainly to everything. They don't submit their scores. If you don't read the directions in kind of summary, then you might not pick that up and you might not send them in. And that could deter your application for up to 60 days with the medical board having to come back and ask for new information. The second one is failure to make a timely request. So if you get rejected and you want to appeal your decision, you are going to need a lot of time. A lot of time. The boards say 60 days. It could run 60 to 120 days in actuality. Submitting your application, I would I say far, far in advance. At least 120 days in advance is critical because if you do get a rejection and you need to appeal and respond to their reasons for denial, you are going to need extra time.
And so a lot of students time out. They run up against entering the Wards and if you don't have -- it depends, a lot of schools are switching their curriculum where students will take step one at the end of year three. If you're still in a curricula that maintains taking step 1 at the end of year 2 before you can go into the Wards you may not be able to continue in your education until you have a passing step 1 score. You can't have a passing step 1 score if you don't take the step 1 exam. If you fail to make the request in a timely manner you are sitting in a situation where you are forced to take the exam without accommodation or take a leave of absence or defer entering into the clinical setting by up to three months just because of the appeal process. Number three, failure to address exam-specific barrier. I see a lot of applications where students say I have ADHD and so I need extra time. That alone -- a diagnoses alone is not going to -- you need to talk about the functional impairment that's a result of the disability and keep it very specific to that. In kind of the counter point is that you also need to keep it specific to the exam.
So it's not just you have a functional limitation but how do you have a functional limitation on this specific exam? What is it about the exam setting? What is it about the exam format and the exam time or the way the questions are presented that causes a barrier for your particular functional limitation? If you do not approach the request in the way a functional limitation and exam specific barrier you won't be approved because they specifically ask for that information. Number four, failure to provide evidence of functional limitation compared to the average person standard. Many of you might know this and some of you may not. But the medical boards are looking at the average person standard. I'll go into more of that on the next slide. I'll hold my comments for that next slide.
Number five, poorly constructed personal statement that work against the student. I've seen several personal statements saying it would be helpful if. I would benefit from. Even though I have a disability I overcame. All of those things are essentially saying I don't need accommodation. It would be beneficial. A lot of people might argue that something would be beneficial but is it necessary to have equal access to the exam? These are the type of word switches that need to be made. It is not been fishltion it is absolutely necessary. It is not -- it would be helpful is, it's mandatory that I have this extra time or whatever to be able to access this particular exam. And the reason is because the exam is constructed X, Y, Z. And never -- if a student says they're overcome their disability they do not need accommodation. Just to be really careful. If you're able to help your students, I know that I was -- I was in a wonderful situation where I had the benefit of time to work individually with each student on their personal statement and I was able to really give critical feedback. But if you can at all, there is on the coalition website, WWW.HSM.org there are some student resources under the resources tab and one of those is MDME accommodations package. It talks about all of the things that I'm talking about now. The use of language. How you present the barrier.
So I would at the very least share that with your students. And then the failure of the school to provide adequate assistance. If you have a student with a disability it is likely they may be struggling just to get through the curricula. If they wait until second year or the end of the second year as they are getting ready to move to the ward there are a lot of exams. There is a lot of pressure and a lot of things going on that they have to do and it may be a really poor time to then be working on something that could take up to 10 to 12 hours. He would equate the applying for accommodations on the MDME to applying for medical school. Maybe not as hard but you need to spend a good amount of time on this.
So schools need to be telling students from day one, you need to be working on this right away straightaway year run if you have updated documentation you need, you need to get that settleded now and work on your personal statement now. A caveat that's not in here -- thank you so much for putting the website on there. Talking in a personal statement about your barriers. Students are used to highlighting their strengths. You only talk about the barriers in this personal statement and to do that could have some psychological effects, to be quite frank. And so as students are going through this they might also be processing what they've been going through and processing their identity as a person with a disability. So it may be difficult to get through this and it may take more time. Programs need to be really proactive in working the students on this. Jan.
Jan Serrantino Cox
Thanks, Lisa. So Lisa talked quite a bit about the student's role in applying for the accommodations but there is a flip side and we hope that you will be helping your students by writing a letter of support. So when you are doing that again this is the process that would take me quite a bit of hours, at least 10 hours to put together a really good, strong argument or a good letter in support of the student getting accommodation. So what are the three key points? You really want to make sure that it's clearly written that the student is actually a person with a disability. And so as you write this letter, you want to refer to the identified diagnoses and the specific areas of deficit, the functional limitations and you want to show how that they are so much -- they are far below the average person's standards. When we look at standard scores, we know that the average person on a standard score is 100 or 85 to 115. And so when you -- when a person comes up with a reading score of 85 or 86, we know we'll provide accommodations for that student but the MDME is laong at that person as well yes, they may have a very high IQ score but their reading is still in the average range. And so we're looking -- you want to make sure that you point out to students if their scores are not in the severely disadvantaged area of like 25 to 30%. They may automatically not be able to get accommodation. So they may need updated documentation or more thorough documentation in a specific area such as reading.
You also want to show their history of disability whether you were first identified. Definitely use numerical data and history of accommodation. The next part in your argument is relating to the disability -- relating the disability barrier to the exam. And so if you don't know what the exam looks like, you really need to go to MDME website and look at sample questions. Look at how they set up the daily schedule for the eight-hour exam. When are the breaks? So you know how the questions are formatted and you know what the graphics or videos look like or how the vignettes are set up. It isn't just like three or four multiple choices. Usually there are eight multiple choice answers and they aren't just a quick answer. They are small passages that a person has to get to. So you really want to be able to look at the functional limitations and directly relate it to the exam -- the barrier that is just in the exam. And then finally, you really want to make a case for reasonable accommodations. And a reasonable --
Peter Berg
Jan, this is Peter. We're getting some feedback on your phone. I don't know if -- at times you were coming in perfectly good and other times a little bit of of feedback like you are moving.
Jan Serrantino Cox
I'm not moving. I am moving a little bit.
Peter Berg
Now you sound great.
Jan Serrantino Cox
Okay. So I'm not sure where to pick up but I'll start with the third notation of making sure that you explain -- you are making the case for how this accommodation is reasonable and that it will allow the student to be able to demonstrate mastery of their medical knowledge. So again, pointing back to the barriers that exist within the exam. The only way that you are going to know that is by really taking a look at how those exams are set up. And hopefully that hits everything that I was pointing to. Next slide, please.
LISA MEEKS
Jan talked about the average person standard. What I have here is a picture of psychological testing normal distribution. I think for a lot of disability-driven providers kind of miss the mark is in thinking that because there is a discep see using the discrepancy model. Maybe a lower score in reading with a high IQ and they carry a diagnosis of perhaps reading disorder or something of that nature, they will automatically qualify for accommodations on the exam. However, they aren't going to. What I tell people is that I have a yellow arrow that is pointing to one standard deviation below the mean. What I tell individuals is your student score is not below that, 85 for the standard score or 15.9% or 16%, something like that. If it's not below that score your student is in the average range. And because your student is in the average range, they are likely not going to qualify for accommodations on board exams.
And there are some references that you can see here. I wanted to give you a full -- there is a full one-hour webinar on this topic that you can go to, the link is there. There is also a -- Jan talked about building your argument and giving a support letter in the guide to accessing students with disabilities with equal access. There is a guide to help providers build that letter. So you can check out those resources. Mike.
Mike McKee
Thank you, Lisa. Super helpful. Also again just really highlighting the key here is preparation, just addressing any needs early on. Again, those are things that are really going to help with the student's success. Then the other thing is recognizing how much extra effort students with different types of disabilities have to do in order to overcome some of these obstacles or even coordinating accommodations. We have one article that Jan touched for deaf and hard of hearing health professional students. We're spending several hours a week trying to coordinate that. It is important to recognize their efforts. To our next question. When examining documentation of disabilities and/or accommodations should there be a time limit on that documentation? For example. Some schools have no limit while others won't except it older than three years.
Jan Serrantino Cox
Thanks, Mike. This is one of those situations where we always say it depend. But if you go back to thinking about what is really the purpose of documentation, it is really two-fold. First of all, you need it to determine eligibility that the student is eligible for accommodation. That's first and foremost what you need. Secondly, you also want that documentation to be able to identify the barriers or the functional limitations that a student is going to experience in the didactic or clinical environment. Having the most current documentation is really helpful. So especially when a student has a disability that is episodic in nature. Like migraines or fluctuating like a mental health condition. So you personally may want to have documentation that is as current as possible. And you may want every year you may want to get some updated documentation. But then again when we have more static-like disabilities or disabilities that students are -- acquire very early in life such as deafness or hard of hearing, low vision, mobility, you may not need that proof. And having something from an old IEP or an old documentation isn't the issue because you can see the disability and you know it's life long. Next slide.
Mike McKee
Thank you, Jan. Our next question is what are some accommodations for color blindness?
LISA MEEKS
I love this topic. My first year at UCSF I had 10 students that had CVP or color vision deficiency and I had to ramp up my knowledge. We wound up writing articles listed in the reference section. But I think first and foremost it's important as health science disability providers for you to understand that 1 in 5 males has CVD. The chances are pretty high that you will have someone that is -- that has CVD or as we said they're color blind. So I think one way to approach it is an awareness and screening. You can provide a CVD statement to incoming medical students or incoming health science students to build awareness saying something like color blindness or color vision deficiency can affect your ability to detect certain clinical indicators.
If you believe you have CVD please alert your instructor. Instructors and students can work to come up with strategies for the different settings. Students who suspect they have it but are uncertain can undergo screening with student health. Being able to provide free and confidential screening for CVD is really helpful. In the classroom and laboratory using black font for all classroom presentations is really important. Having special items notated with arrows or using numbers or letters versus color, a lot of times people will color code things instead. This is where universal design approach. Using numbers and letters would be helpful. Use green laser pointers. One of the first things that I did was most pointers are red. I had to order all green laser pointers for our faculty. In the gross anatomy lab was we provided high quality gray scale print alongside each microscope. We did it for every students. Regardless whether you had CVD. If you had access to a high-quality grade scale print of the slide. Students were able to have the slides also transitioned to high-quality grade scale to study from that so they would be studying the same type of figure that they would be tested on. Making assistive technology available for students with CVD. You could do covered overlays and special glasses and color converting software programs that help turn things to high quality gray scale. Using alternative color scheming in your specimens. Not using red or green but using another type of stain to do this. And then for the clinical setting, using reflectans meetings instead of looking for a scale of red. I'm trying to think of the test that has the strips that are red. I can't remember. Oats a urine test and checking with colleagues for color dependent diagnosis. The ability to defect fresh blood from old blood. That's very important in making a diagnosis as times. Also when looking at an ear, deciding whether or not a child, for example, has an ear infection. Focus on the shade versus the color. So again transitioning things to high-quality gray scale and focusing on shade and making sure you take a good patient history and report of symptoms. As one other way to triangulate your differential in a clinical exam and for observation. And then utilizing apps -- applications on cell phones for high/low B and white contrast in conjunction with some desizes. There are a couple of things out there that I talk about a lot. I love the cell scope. One reason I love it so much. An adapter for an I-phone to use as an otoscope. We talked about that in the original webinar. If you didn't see the original web nor go back and look at that. One of the great things about the cell scope. When you're doing an examination of a child in her ear you can use an app to turn the color to high contrast gray scale so you can have a more accurate diagnosis. In the references you'll see there are some articles that talk about the different things you can do to support students again in the guise of assisting students and there are quite a few articles that were written on this topic that you can pull up and go to for more information. Mike.
Mike McKee
Thank you. So our next question that we received is an example of technical standards that could be considered for nursing programs?
Mike McKee
The next slide.
So this is a topic that many of us struggle with, especially with technical standards that could be perceived as discriminatory. The technical standards are in place to help out different institutions, different training programs, to help to see or judge the qualifications and eligibility before they mat I canry late into program. There is a version of the technical a standard that we perceive to be restrictive. Generally deficit based. Using myself as an example, an organic technical standard would have am I able to hear? And this is not with accommodation. So if there was a restrictive technical standard I would not be eligible for that program. That would contrast with a functional technical standard which is would I consider to be much more progressive and more current. These are based on abilities with or without accommodations. Am I able to do the job? In my situation, if I were to use an amplified stethoscope would that allow me to do the job of being able to listen to heart sounds among sounds? In that case I would. I wanted to make sure people were aware of those two different categories of technical standards. Let's go to the next slide.
So as I mentioned, schools -- we need to make sure they don't impose or apply eligibility criteria that are going to be discriminatory or screen out individuals with disabilities. Many of them are unintentional but I would encourage you to review your technical standards. Some of you might be surprised on some of the language that is used. And so it's important that we need to review these technical standards periodically to make sure they're current add not discriminatory. Next slide.
We put a slide here to provide what we consider discriminatory technical standard. Communication, a candidate should be able to speak, to hear, and to observe patients in order to elicit information, describe changes in mood, activity, and posture and perceive non-verbal communications. Communication includes not only speech but reading and writing. The candidate must be able to communicate effectively and efficiently in oral and written form with all members of the healthcare team. That would be an example of a discriminatory technical standard. If it was an individual -- a deaf individual using a sign language interpreter doesn't use their language and speech would be discriminatory to that particular student. We'll give an example of what we consider to be a better written technical standard. In this case some language we would change here. We're now students should be able to communicate with patients in order to elicit information, detect changes in mood, activity and to establish a therapeutic relationships. The ability to care and manage patients. If they're able to do it with or without accommodation, that should be the focus. Go back. At this point here students should be able to communicate by effectively and sensitively with patients and all members of the healthcare team both in person and in writing. It provides for flexibility between patients and the healthcare team.
A number of strategies we encourage you to do. I would encourage you to go to your institution's technical standards. They're not easy to find. That poses a problem especially for students that are interested in applying to your program. Many of them are trying to locate it. If it is difficult to find you may want to mention to different folks putting in a better petition or a better place on with website. You want to make sure that you highlight to what -- not the how, as well as providing directions on how to request accommodations. You want to be up front we're not trying to focus on the deficit but really we have accommodations focused more on the ability of a student. Then making it more welcoming for students with disability and it's really about efforts with the diversity and inclusion. We want to have a diverse healthcare workforce and one way to do that is to make sure that we also address our technical standards and make sure it's not discriminatory. Then the other thing is all technical standards should be met with or without accommodation. It will be a case-by-case basis but it's important to highlight that they can make these in class. Lastly, students just sign attesttation each year that we've reviewed this.
LISA MEEKS
This is an example of technical standards. Right now Rush is leading the pack. Schools are changing their things to be more accessible. This is the Rush website. The reason I chose to share a snapshot of Rush is because many of you come from a myriad of different programs and Rush has several health science programs so you can find an example on each. I wanted to read a portion of their opening statement and it says rush actively collaborates with students to develop innovative ways to have a respectful. Accountable culture through our disability support. Rush is committed to accessibility. We want people with disabilities to disclose and seek accommodations. I would be hard pressed to find a school that is that good. They have done an excellent job of communicating how committed they are to having a workforce that mirrors that of their patient population and that includes individuals with disabilities. There are some references and you'll see that I believe Mike is on some of these papers, but these are some references to papers on technical standards. The KEZAR is a med-ed focussed -- a few references for you.
Peter Berg
Lisa, just as a reminder, we have 30 minutes left in the session.
LISA MEEKS
Great. Thank you.
Mike McKee
So our next question that we received are essential functions the same as technical standards? Next slide.
So these are really considered to be the same as core competencies. What we try to do is now think about a student who has already been mat Rick lateed and looking to see if they're qualified to do the job and after they did the enrollment and move onto their extra levels of training or if they want to go ahead and look for employment. So these are really based on knowledge, skills and abilities a student has to demonstrate. In my case, I'm in family medicine, I need to be able to care and manage our health physicians of different ages from newborns to older ages. We have a wide variety of core competencies we have to demonstrate and be able to tackle. Next slide, please.
LISA MEEKS
Technical standards before and essential requirements or core competencies after. The essential requirements are things you learn when you're in the program and every program should be making these transparent, should have a list of everything that needs to be learned, so what must a student know. What has to translate to practice, what does the student have to be able to perform. From family medicine you go from infants and newborns to gear geriatric patients. Students have experience with a core competency. And core competencies should be clear and concise and measurable so you can have objective measures across all students, not just students with disabilities. And behavioral expectations should be part of the competency and be measurable. You should be able to map a core competency to an actual practice. You couldn't say in a nurse being program you must be able to stand on your head for 30 seconds. It makes no sense. And when you go out into the employment world. You have to be able to map these on actual practice or some sort of accreditation and employment things. Next.
Mike McKee
Our next question is what other professional resources are available to help identify software, hardware, special tools or techniques and strategies that might be considered for reasonable accommodations? We briefly provided some examples with the job accommodation network, coalition list serve and the guide occupational therapists and AT specialists. There are a number of career goals in terms of what type of disability they may have with the student. There may be organizations with their type of disability. In my example I work closely with the organization of medical professionals with hearing loss and we have an upcoming conference June 1-4. This is an organization that has a lot of resources, networking opportunities, advocacy for opportunities that have hearing loss. Next slide.
So our next question is the in private or for-profit medical schools, do they only consider the operating budget of the school itself such as undo youment or projected income.
LISA MEEK
Any school receiving federal dollars are subject to the ADA. There are minor differences, it is type of accommodation. If all the accommodations would provide equal access. It's really focused on the cost or funding. We'll defer to your legal counsel on the budget and so I would suggest that whomever asked the question or anyone struggling with this type of question go to their legal counsel. I do want to note that there was a private Jesuit university and could not argue because the cost of accommodations was up to $250,000. Keep that in mind.
Mike McKee
Thank you. So our next question is are there examples of recommended language to include in notes to students or preceptors about their responsibilities?
LISA MEEK
So I'm going to defer to the UCSF website. It maintains language for both students and faculty. And I think that they do a really good job and they post -- this is a snapshot of the UCSF webpage. They post all of their policies and procedures on their website. And it has really good guidance for preceptors and students. And if the website does not contain what you're looking for I would encourage you to reach out to the SDS office because they have lots of example to share with you.
Mike McKee
Thank you. This again highlights the importance of allowing opportunities for students with different types of disabilities to meet future preceptors. Many of the preceptors often may not have experience working with these students and so having that interaction early on can be really critical to identify any specific areas in which the accommodations might be needed. So our next question was the interpreter required at John Hopkins for disability, like hearing, or for language barrier? So the quick answer is this was based on hearing. This is our -- this particular nursing -- a nurse who was deaf. She was not able to access language or information in other ways so this was under the hearing loss or disability not language barrier. Our next question. Are there any accommodations or assistive equipment for severe stuttering? The answer is yes. We'll provide you more information.
Jan Serrantino Cox
I think it's Lisa, do you want to take that one?
LISA MEEKS
As I said in the beginning of the webinar, we are going to point you to a lot of resources. There were lots of questions and a lot to get through in an hour and a half. This is an article in the coalition corner, a subsection of the higher ed. and disability resource. So for those of you who subscribe, you will have this disability compliance in higher education. For those of you who don't but have a library it is probably covered in your library. I gave you the information to look up the article. I wanted to briefly talk about some of the modifications. So one would be text to speech features on an iPhone or iPad. The student could text and have the iPhone and iPad do the talking. Extended time. Short rehearsed statement disclosing their stutter before seeing a patient. Pre-notification to preceptors. One of the worst things you can do for someone who stutters is try to finish their sentences. Just some education around how to work with someone who stutters would be helpful for preceptor. Rehearse common oral clinical interactions with a standardized patients in a sim lab. Putting the students in a situation that simulates what will happen in the clinical setting so they can practice those interactions. Rehearsing for OSCE exams. And again using that same badge we talked about with the students on the spectrum as an outline for patient presentation to help students focus their speech and education to the people who are going to work with the student about how stuttering, what stuttering is and what it isn't. How to work with these individuals. I did want to put a note in there. I put a link to a YouTube video. A Harvard trained physician and professor, best selling author as well. She just took the Presidentsy of planned parenthood maybe in the last year and a half. Highly successful and she stuttered through high school. It talks about her stuttering in this video. I put it here as an example to say it can be very successful in the workplace. I have a physician personally who stutters. Having the patients to give him time to finish the sentence and not jumping in and using some of those other helpful tips is -- has been really successful in working with him.
Mike McKee
Thank you, Lisa. Is it the responsibility of the school or the individual to purchase these modifications? For example, if a student did not have an iPhone would the school need to purchase one to use with the cell scope or is the ONUS on the student to purchase modification items for their accommodation requests?
Jan Serrantino Cox
I'll take that one, Mike. There are several answers to that question. First of all, if equipment is needed in the hospital, that's probably that you as a disability service will provide for the student. A student might need a smart pen in taking notes and being able to do it accurately later in the day. So you would develop a protocol to make sure that smart hand is erased every day and locked up and patient information is protected. And then we look at something that might be a student's personal device like if they don't have an iPhone. Is the student only going to use it to use the cell scope or will the student use the device as their regular phone? So if it is going to be a personal device we know the offices won't purchase it but maybe the cell zone. The other thing to think about is in my situation we might start off by purchasing a piece of equipment and allowing the student to use it under certain protocols. But then when the student is getting ready to graduate they want to take it with them and so we look at how long we've had that device and if we end up selling it to the student. Otherwise you would keep devices for the next time you need it with a different student. Next slide.
Mike McKee
Thank you, Jan. Are there mechanisms of compliance or enforcement available to students? Quick answer there are but one thing I wanted to highlight is that often education will address many of these issues of compliance or failure to provide accommodation. So I want to emphasize that education both students and also any advocate mentors can really be instrumental in addressing many of these. The other thing is if that's not successful there are ways to file grievances. That might be through the office for students with disabilities will help with that. Some places have an ADA office, as well as outside go-to the office for civil rights as well as retaining and having access to an attorney for formal litigation. Those would be the last resort and hopefully education will help in breaking down many of these barriers. Our next slide.
What is the best response to a professor concerned about future requirements? Particularly in situations where they may use these concerns as a reason to deny accommodations in their current program?
Jan Serrantino Cox
Okay. So --
Mike McKee
Jan, I believe that's you.
Jan Serrantino Cox
Sorry, Lisa. Well, in this situation we want to make sure that we're focusing on program competencies and not really what is going to happen later on. And so we do know that in the real world or in the future workplace accommodations are going to be available to students that need them or to employees that need them. But at the same time while the student is in the program, they have to meet core competencies outlined in the program. Not what is going to happen later on. So it's really important again to know what is in the core competencies for your particular programs. For example, some programs have items such as CPR, CPR life insure or CPR eligible and that is a part of the core competencies within a specific program that a student has to have that. And so we want to make sure that we're not focusing on what -- we're focusing on what all students have to do. Not necessarily the student with a disability can and cannot do.
Next slide.
Mike McKee
Thank you, Jan. What's the best way to accommodate a student for one clerkship where they have to make up the clerkship at a later date without it feeling like a punishment? For example, during their study break, summer break, research opportunities, etc. Again, this is really dependent on each program. How they are having it set up. So there is really no -- one specific answer that can apply to everybody. This needs to be perceived that we're trying to find the best strategy to make it work. There are multiple parties involved with that but this really kind of depends on the program. Next slide. Our next one is there guidance or suggested resources available for accommodation requests for students with mental health problems like depression and anxiety?
LISA MEEKS
So we have a couple of sides for this. We get a lot of questions about this. What I would say is that, you know, if you're having difficulty with somebody that has a psychological disability. If the behavior our communication or professionalism is not where it should be, then certainly he need to go back to the technical standards and sit down with student and explain why they aren't meeting the technical standards or on the flip side meeting the core competencies which we've articulated should include a behavioral standard. I want to talk about the things that might occur with the students. A student that has a history of mental health diagnoses or difficulty functioning around patients may be susceptible to situational stress. Medical schools or nursing schools may be the most stressful thing they've ever gone through in their lives. Personally I think the one year, you know, zero the nurse programs that are out there are the most stressful programs that exist in health so the situational stress may be impacting students that they won't be impacted on an everyday basis once they graduate. Managing patient workload. Whether or not the student can mitigate that through accommodations or reduced patient panel for a limited time. Make sure that your students are situated such that they can attend to weekly -- they have release from clinic to do so. This is critical to maintaining well-being. Also managing triggers so students can be triggered by a number of things and it's helpful to talk to your student to find out exactly what is triggering them and then look to see if that will be problematic on the ward. Flexibility in the program, course load or order of clinical rotation. Those of you in medicine, making sure that medicine -- internal medicine, surgery and OB/GYN aren't situated so they're one after another. It is helpful in helping a student mitigate stress. For some students with psychological disabilities and for students with chronic health disabilities sometimes decompressing the clinical year into either two years or a clinical year and some months can be highly helpful. For those students have that title IX, we have students who have survivors of sexual assault. If that's the case, making sure you're working closely with your title IX person is Paramount. Jan.
Jan Serrantino Cox
So in the next slide we have a list of standard accommodations that you could consider for someone with a mental health disorder and one of the easiest things, or one. Simple thing to consider is decompressing the clinical rotation. If it's a four-week rotation, maybe you look at extending it. Shorten the amount of time during the day and move it to six or eight weeks. So what you do is decrease the hours per day but then they can make up some of the time on holidays or weekends. Remediating skills without putting your mediation on the transcript is really helpful. Looking at housing. Some type of alternative housing situations. And then if someone needs to go on a leave of absence, that they're allowed to stay in the program and stay in housing, keep their health insurance. Financial aid is also something important for you to look at. We know that when students might go on a leave of absence that it must kick in repayment of loan. And so it's important to know that for at least the first six months that they can be not in a repayment mode but after that they may need to ask for an extension or forbearance so they can continues on a leave of absence. In a didactic setting have time away for appointments or have a private location to do a Skype or phone appointment. Having flexibility in time lines. Getting copies of notes are some of the others are more standard accommodations for opportunities. Let's go to the next slide.
We'll look at some possible clinical accommodations. Again, looking at the placement site. Making sure it's a site that is accessible for the student, that it is not a place where they have been a patient before or they're receiving treatment. And it's a site that is located -- it's in a location where they can still make their own -- make it to their own appointments. Making sure that there is an allowance to be able to withdraw from the site or to rearrange their current schedule. Doing charting the night before. Get -- trying to move along quickly. Giving them the opportunity to have a look at chart -- patient charts the night before so they can prepare. Changing from a male or female preceptor to one that is more helpful in the situation that the student is in. Especially if they're PTSD because of sexual assault you would want to get them in a situation where they had a preceptor that wasn't a perpetrator. Stepping away briefly to care for their personal needs if they need an extra absence. And understanding that they may need to adjust clinical hours if they are going into a significant quair. Previewing the site ahead of time is so helpful to our students. Changing the order of retation can be helpful. Splitting up those very challenging rotations like surgery orthopedics, OB/GYN and putting in the easier, shorter rotations in between. And then making sure that students are able to address their sleep hygiene. They might not have overnight call or they might have a hard stop that they can work into the evenings and stop at 10:00 so that they have adequate time to take care of their own personal health. And then making sure that they are able to get their clinical competency at a trauma center at a different location than one that they may have visited as a patient. Next slide.
LISA MEEKS
I'm going to skip over the accommodation or leave of absence. I encourage everyone to look at these four slides. They're pretty self-explanatory. It is important to make sure that you understand the best practice for leave of absence and that students aren't being forced to take a leave but that you also understand unintended consequences. I wanted to get back to some of the technical standards questions and Mike, if you want to go ahead with this question.
Mike McKee
Yes. Is there any guidance or resources to develop technical standards for applied healthcare fields? This is related to occupation Altherr pee, physical therapy, speech, language, whose technical standards might look a bit different than medical education?
LISA MEEKS
We've given you a bunch of articles developing technical standards. The KEZAR article that's highlighted. And another one have examples of technical standards using the organic versus functional as Mike was talking about later. Given the time constraints, we're going to just forward to the resources. We talked about a centralized -- Mike, if you want to read the last question and we'll talk about the resources that are available.
Mike McKee
Is there a centralized tool box that might describe accommodations for health/medical students? Some students may not be sure exactly what to ask for.
Jan Serrantino Cox
There are so many supports available for you as disability service providers. In the next slide we have the coalition for disability access in health science. If you aren't a member of the coalition, I want to highly encourage you to look at the benefit of becoming a member. You can become an individual member or institutional member at very low cost. I think institutional membership is maybe $125 a year for up to five folks but through the coalition you have access to so many colleagues around the nation who are experiencing and having the very same questions that you are. So on our website we have a lot of resources. We have faculty support resources. There are free webinars that you can use. For faculty and for training that won't cost anything. And these are training that faculty can do on your own or they can be part of staff meetings. There is other articles that are being added regularly. And so there is quite a few resources there, including speaker's bureau and training opportunities for your campus.
LISA MEEKS
For your students looking for a community to join, the national medical accessibility coalition on Twitter is a great community that was started by students and it includes trainees from the U.S. and Canada that are advocating for disability access in health provisions. NMAC tweet and you can find them on Twitter. Twitter is having amazing conversations right now about disability inclusion in health sciences including the docs with disabilities campaign that came out of the University of Michigan family medicine department. I have a snapshot here. Search and you'll see all kinds of discussions and resources and Mike, do you want to talk about M disability?
Mike McKee
Yes, M disability is really just a branding of our department program that we have here and this was newly established a couple months ago. Lisa and myself and also spare me a few other individuals who are now with faculty. This department is focused on department ways to not only improve the health of our people with -- patients with disabilities but we'll also have a focus on students with disabilities in order to improve access, knock down some barriers but also provide pipeline programs. So we're going to be setting up our website very shortly but we have our Twitter account now at disability underscore UM. We want to mention the Association of medical professionals with hearing loss also. That's also another great resource with students who have hearing loss.
LISA MEEKS
It is fantastic. Here is a breakdown of resources that you can use. I do want to point out that all of the resources listed here are completely free, completely accessible. Our goal is to help you get the information you need in a timely manner. I'm sorry we had about 20 slides that couldn't be covered. Just very generally a lot of the questions were about what do you do when your program says you can't do this because of your accrediting body. Go to that website and look at the language. They have excerpts of language on the sides but you have to follow federal guidelines. If your department is giving you pushback about accreditation you go and look at what the a-- what they say. This is great that this is fully accessible and happy to have these resources out there. I think making sure that people know about them is critical. 20-minute trainings for faculty, there is a link and webinars on disability applicable to all health signs. All of these are centralized quickly at the coalition website. A great place to start. Great you're asking this question and the needle is moving. Really far over the last four years and so we appreciate the work that you are doing, you are in the trenches doing this work every day and we want to provide support and resources for you to continue to do such a great job. It's always a pleasure to speak to disability service providers and it is always if you have questions feel free to reach out to us. I'm sorry we couldn't get to every question. This is just one of those constant struggles when there is something new and we have lots of questions to answer. But know that there are lots of resources that guide to assisting students with disabilities. Although it is not listed here it is available now and the second edition is coming out in 2020. There will be lots and lots and lots of resources for you.
Peter Berg
Excellent. Thank you all very much, Lisa, Mike, Jan with a wealth of information you have just provided us to. A quick reminder that the hand-out for the PowerPoint that was used will be posted with the archive so you will have access to all of the information and all the great resources that our speakers put together for you. Real quickly our next audio conference session will be June 25th. Please note the date. It will be the fourth Tuesday of the month instead of the third Tuesday. We'll be looking at effective communication, what does that mean? You can get that information and access the archive from today's session along with the hand-out when it becomes available by visiting ADA-audio.ORG. Thanks to our speakers and to all of you for joining us. Have a great day and take care.
Mike McKee
Thank you.