Briefing Note Re Envisioning Technical Standards In Medical Education.23.10.04

Re-envisioning Technical Standards in Undergraduate Medical Education in Canada I. PROPOSAL _____________________________________________________________________________________ 1 II. BACKGROUND __________________________________________________________________________________ 2 III. FOUNDATIONAL CONCEPTS __________________________________________________________________________ 2 IV. RATIONALE AND CONSIDERATIONS _____________________________________________________________________ 2 V. DESIRED OUTCOME _______________________________________________________________________________ 3 VI. EXEMPLAR LANGUAGE FOR ADMISSIONS _________________________________________________________________ 4 VII. KEY MESSAGING _________________________________________________________________________________ 4 VIII. DRAFT FUNCTIONAL ABILITIES FOR STUDENTS ENTERING AND COMPLETING MEDICAL SCHOOL _____________________________ 6 IX. RECOMMENDED CONSULTATIONS _____________________________________________________________________ 7 X. ANNOTATED BIBLIOGRAPHY _________________________________________________________________________ 7 Meeks (2020) ___________________________________________________________________________________ 7 The Future of Admissions in Canada Think Tank (FACTT) (2020) ____________________________________________ 7 Curry et. al. (2020) _______________________________________________________________________________ 8 Stauffer et. al. (2022) _____________________________________________________________________________ 8 Statistics Canada (2018) ___________________________________________________________________________ 8 Gulli (MacLeans) (2015) ___________________________________________________________________________ 8 Battalova (2020) _________________________________________________________________________________ 9 Accessible Canada Act (ACA) (2019) __________________________________________________________________ 9 DeLisa et. al. (2012) ______________________________________________________________________________ 9 CMA 2021 National Physician Health Survey (2022) 13 : __________________________________________________ 10 Kezar et al. (2019) _______________________________________________________________________________ 10 Stergiopoulos et. al. (2018) ________________________________________________________________________ 10 Stergiopoulos and Martimianakis (2023) _____________________________________________________________ 10 Reichgott (1996) ________________________________________________________________________________ 11 Jain et. al.(2022) ________________________________________________________________________________ 11 Mace Basic Principles of Universal Design (1990) 20 : ____________________________________________________ 11 XI. REFERENCES ___________________________________________________________________________________ 13 XII. WORKING GROUP MEMBERS _______________________________________________________________________ 15 XIII. APPENDIX 1: LEGISLATION PERTAINING TO PERSONS WITH DISABILITIES ___________________________________________ 16 LEGAL REQUIREMENTS: ________________________________________________________________________________ 16 CANADIAN CASES INVOLVING A POST-SECONDARY INSTITUTION AND DISABILITIES: _________________________________________ 18 OTHER INFORMATIVE POLICIES, STATEMENTS ETC. ______________________________________________________________ 18 I. Proposal We propose to re-envision the current Technical Standards and redefine functional abilities required to study the practice of medicine; adopting a Functional Ability 1 approach for such standards thereby minimizing the barriers for people wishing to enter Canadian Medical Schools, particularly students with disabilities, who have been deterred and excluded by ableist assumption embedded within technical standards. We recognize that medical education is a continuum, and these standards will be specifically applicable to undergraduate education but will influence learners at all levels of medical education. Functional technical standards identify specific competencies a student must achieve in their training, without specifying how they accomplish these competencies. This reframing of technical standards allows for accommodations, including assistive technologies, and affirms that the presence of persons with disabilities within the medical profession gives it strength by virtue of the unique perspectives and experiential expertise that persons with such lived experiences may offer to the wider medical community and to patients. This is one of the ways that Canadian medical education can play a leading role in promoting epistemic justice in medicine. We welcome collaboration with other human health professional education programs in adopting parallel approaches. 10/4/2023 2 II. Background Leaders in Canadian medical education have called for greater equity, diversity and inclusion across the admissions process 2 . However, outdated technical standards, which define the specific ways in which functional abilities must be demonstrated to enter medical training, risk excluding learners with disabilities 3,4 . One in five Canadians experience disability in their lifetime 5 ; therefore, medical learners with disabilities provide valuable experiential expertise and help to create a profession that better represents the population it serves 6,7 The Canadian Human Rights Act and Accessible Canada Act 8 mandate that all people, including those with disabilities “must have barrier-free access to full and equal participation in society”. Further, there are provincial accessibility acts of note (see Appendix 1). Legislation notwithstanding, current technical standards remain a barrier to persons with disabilities entering medical schools 9 . III.Foundational Concepts Disability has been defined in various ways, by different groups, and for different purposes. Many Canadian and international policy documents use the World Health Organization’s definition 10 , where disability is an umbrella term that links variability in body/mind function or structure with an activity limitation or a participation restriction in an individual’s social and/or physical environment. The Accessible Canada Act 8 defines disability as “any impairment, including a physical, mental, intellectual, cognitive, learning, communication or sensory impairment — or a functional limitation — whether permanent, temporary or episodic in nature, or evident or not, that, in interaction with a barrier, hinders a person’s full and equal participation in society. Disability Accommodation refers to academic adjustments and auxiliary aids that enable students with disabilities to have access to education equivalent to that of their non-disabled peers. The purpose of accommodations is to ensure that all students – with or without disabilities – have an equal opportunity for success 11 . Duty to Accommodate Reasonable accommodation is a legal term of art that references obligations under human rights law. Accommodation to the point of undue hardship is another way to state the obligation. Each jurisdiction (federal, provinces, and territories) in Canada has its own human rights legislation and, while specific wording may vary, decisions on the duty to accommodate has been articulated by the Supreme Court of Canada and are generally considered to be applicable to all of the individual human rights statutes. As well, equality rights under the Charter have been held to similar principles in relation to whether or not differential treatment that is harmful is a violation of the Constitution. Context in application of general rules and principles in this area of law is very important. Note also that the government, including public sector entities, generally will have a hard time making certain arguments that accommodation is a hardship and therefore not reasonable. IV.Rationale and Considerations The spirit of this document is both an affirmation/cultural approach 12 and a human rights approach; recognizing that disability is a valuable aspect of human diversity to be embraced, is common among Canadians 5 and Canadian physicians 13 , and is a protected human right under The Accessible Canada Act 8 . 1. Disability is common. One in five Canadians experience disability 5 in their lifetime. In a Physician Health Survey conducted by the Canadian Medical Association in 2021, 23% of Canadian physicians reported having a disability 13 . 2. Physicians and learners with disabilities provide exemplary care to patients based on both their education and their experiential knowledge 6,7 . 10/4/2023 3 3. The Association of the Faculties of Medicine in Canada (AFMC) Future of Admissions in Canada Think Tank (FACTT) report defines persons with disabilities among the three underrepresented groups that warrant national policy and accreditation changes 2 . 4. The Technical Standards for many Canadian Medical Schools are derived from the 1979 AAMC Special Advisory Panel on Technical Standards 3 and do not fully consider the ongoing technological advances, changes in legislation (Accessible Canada Act 8 ), and emerging practices in the domain of disability inclusion, especially in the Canadian context. A survey of US medical schools’ technical standards found use of restrictive language while also indicating their willingness to accommodate students with disabilities 4 . This creates hidden curriculum and leads to indirect discrimination toward disabled students and creates legal risk for medical schools. 5. The current language and implementation of Technical Standards have not kept pace with advances in modern assistive technology and access strategies used by people with disabilities generally and by healthcare providers with disabilities specifically 4,14 . 6. Medical learners with lived experiences of illness and disability offer critical insights about curricular messages of the ‘good doctor’ based on their experiences as patients, providing important considerations for curriculum and faculty development 15,16 . 7. Medical schools may need to re-examine the conception of the "undifferentiated graduate" as being capable of performing the history, physical examination, and any medical procedure without an intermediary 17 . 8. Concerns about disability inclusion and the “real world” of medicine must be met with recognition of the capability imperative (compulsory hyper-ablebodiedness and mindedness) as a context-specific manifestation of ableism 18 . 9. Ideally medical schools would demonstrate social accountability by actively recruiting learners who contribute to a more representative physician population and track outcomes of those recruiting strategies including longitudinal assessment of their experience broadly throughout undergraduate and postgraduate medical education 19 . Additionally, schools would ideally recognize the additional labour of learners and educators 20 in co-creating access in clinical settings. V. Desired Outcome All Canadian Medical Schools will: 1. Promote a cultural shift to create institutional support for reasonable accommodations and accessible learning environments that promote wellbeing and belonging where all learners can thrive. 2. Adopt a Functional Ability-based approach 14,17 to technical standards for students entering and completing medical education, that clearly specify requirements for successful completion of undergraduate medical education with flexibility on how those requirements are met. 3. Provide institutional support that includes a specialized team that understands healthcare/medical education and can partner with students with disabilities in creatively navigating strategies and implementing reasonable accommodations to meet functional abilities and to thrive in the learning environment. Ideally this specialized team would be outside of Faculty of Medicine, or at least in a designated office where confidentiality can be assured, and conflicts of interests are not present. 4. Integrate the principles of universal design 20 to create policies, assessments and learning environments that work for all learners. 10/4/2023 4 5. Promote alignment across the medical education continuum, advocating for support for learners with disabilities entering postgraduate practice and encouraging others in the cycle of becoming a physician in practice. VI.Exemplar Language for Admissions Offer letters of admission should include a reminder for accepted students to connect with disability resources as soon as possible after acceptance to make certain accommodations can be in place. This should be in all letters as some students will not have disclosed during the admissions process. “[ name of program] maintains a strong institutional commitment to equitable educational opportunities for qualified students with disabilities who apply for admission to [degree program] or who are already enrolled. The functional abilities are not intended to deter any candidate for whom reasonable accommodation will allow the fulfillment of the complete curriculum and meet the required learning outcomes. Admitted candidates who disclose accessibility needs will partner with [name of office], appropriate health/rehabilitation professionals and relevant educators to determine whether reasonable accommodations or alternative mechanisms would permit the candidate to satisfy the standards set out in this policy. If you are an applicant with a disability who may require accommodations in our program, we encourage you to contact [name of person] at [email and phone number] for a confidential consultation that will not impact your admission process. The assessment of your accommodation needs is completely separate from the evaluation of your candidacy for selection into medicine. We ensure this by having your accommodation needs be assessed in a different office of the University, which has no evaluative role in assessing either you or your file. Your accommodation needs assessment will not impact upon the evaluation of your candidacy. The following functional abilities (knowledge, skills, and behaviours) focus on the students’ abilities with or without the use of reasonable accommodations or assistive technologies, and in conjunction with the academic standards, are requirements for admission, promotion, and graduation. The term “candidate” refers to candidates for admission to medical school as well as current medical students who are candidates for retention, promotion, or graduation.” VII. Key Messaging 1. Disability is viewed as a vital part of diversity, and as such, programs will actively seek to ensure their program is accessible and inclusive with reasonable accommodations being made to ensure students with disabilities feel welcomed, supported, and have the same opportunities as their peers to complete the program requirements. 2. Programs will create a safe and inclusive environment, whereby candidates are encouraged to seek accommodations based on functional limitations as a result of bona fide medical condition(s), outlined by candidates’ medical practitioner. 3. Programs will respect a student’s expertise in their own disability, and actively partner with the student to address access and accommodation needs. 4. Programs recognize that technological advances are available to aid in meeting functional abilities. 5. Programs commit to partnering with all clinic settings for learning (clinical affiliates) to ensure learning environments are accessible including the physical spaces, didactic material, experiential opportunities, and social opportunities. 10/4/2023 5 6. Programs recognize the institution’s legal and financial responsibility to bear the cost of reasonable accommodations, in partnership with the clinical affiliates. A programs commitment to partner with learners with disabilities is clear. 7. Candidates are reassured that conversations and communications regarding their disability-related information will be confidential and respected. 8. Candidates know that specialized support for accommodations is available, by people who have appropriate expertise in disability inclusion, accessibility, and the nuances of clinical work and where they may lack in expertise, they will seek out that expertise. 10/4/2023 6 VIII. Draft Functional Abilities for Students Entering and Completing Medical School (adapted from Reichgott 17 and Kezar 14 ) Functional Ability Description of Ability (with or without reasonable accommodation or assistive technologies) Learning Candidates/learners in the program learn through a variety of modalities, including, but not limited to, classroom instruction; laboratory instruction, including cadaver lab; physical demonstrations, small- group, team, and collaborative activities; individual study; preparation and presentation of reports; and use of technology. Communicating Candidates/learners in the program • Exhibit interpersonal skills to accurately evaluate patient conditions and responses and enable effective caregiving of patients. • Record information clearly and accurately and representing patients' perspectives accurately. • Demonstrate effective communication, participation, and collaboration with all members of a multidisciplinary healthcare team, patients, and those supporting patients, in person and in written communication. Interpreting Data Candidates/learners in the program effectively interpret, assimilate, and understand the complex information required to function as a medical student including the following: • Comprehend three-dimensional relationships and understand the spatial relationships of structures; • Synthesize information both in person and via remote technology; • Interpret diagnostic representations of patients' physiologic data; • Interpret causal connections and make accurate, fact-based conclusions based on available information; • Formulate a hypothesis, investigate potential interventions, and reach appropriate conclusions. Integrating Knowledge Candidates/learners in the program • Conduct physical examinations and diagnostic maneuvers to form an accurate and comprehensive assessment of relevant patient health, behavioural, and medical information. • Respond to emergency situations, based on level of training, in a timely manner. • Comply with safety standards in the learning and clinical environment, following all applicable universal precaution procedures. Demonstrating Professionalism Candidates/learners in the program • Practice within their level of competence, incorporating the required knowledge and skills to deliver quality patient-centred care. • Take appropriate actions in situations where they do not have the required competence to deliver quality patient-centred care. • Demonstrate engagement in self-reflection to identify learning needs and objectives to maintain competence. • Demonstrate capacity for team-based care of patients with intra-and-interprofessional colleagues. • Respect boundaries, confidentiality, and privacy for all individuals in a respectful and effective manner regardless of gender identity, age, race, sexual orientation, religion, disability, or any other protected status. • Function within, the legal and ethical aspects of the practice of medicine and maintain and display ethical behaviors commensurate with the role of a physician in all interactions with patients, faculty, staff, students, and the public. 10/4/2023 7 IX.Recommended Consultations AFMC Undergraduate Medical Education Deans Committee AFMC EDI & Anti-Racism Committee AFMC Standing Committee on Social Accountability AFMC Postgraduate Medical Education Deans Committee AFMC Admissions Network AFMC Student Affairs Committee AFMC Clerkship Network AFMC Pre-clerkship Network AFMC Clinical Skills Network The Federation of Medical Regulatory Authorities of Canada (FMRAC) Medical Council of Canada (MCC) Canadian Association of Physicians with Disabilities Canadian Federation of Medical Students (CFMS) Féderation médicale étudiante du Québec (FMEQ) Committee on Accreditation of Canadian Medical Schools (CACMS) College of Family Practice Canada (CFPC) Accreditation Committee Royal College of Physicians and Surgeons of Canada (RSPSC) Medical Schools will need to consult internally as well. This will include Center of Accessibility/Student Accessibility Services (or equivalent), Legal Counsel, governing committees, and other bodies, as required. X.Annotated Bibliography Meeks (2020) 1 : This book chapter outlines the difference between organic and functional technical standards (TS), and provides a roadmap to revising TS including current best practices. In contrast to organic technical standards, a more progressive view is based on functional technical standards that focus on the students’ abilities, with or without the use of accommodations or assistive technologies. The use of functional technical standards can assist in removing barriers that prevent students with disabilities from entering health professional education programs and then into health professions, improving the diversity of the healthcare professional workforce. Functional technical standards allow students with disabilities to include rapidly developing, cutting-edge assistive technologies (e.g., amplified stethoscopes, specialized motorized wheelchairs, magnifying devices) and accommodations (e.g., extended test times) to meet technical standards of the health professional school or training program. Programs across the country are successfully implementing this approach, and stories of these successes are making their way to the literature. The Future of Admissions in Canada Think Tank (FACTT) (2020) 2 : The FACCT Proposed Strategy for Enhancing Admissions report to the AFMC explores national consensus on the definitions of diversity and social 10/4/2023 8 accountability and defines persons with Disabilities among the three underrepresented groups that warrant national policy and accreditation changes. According to Canadian Association of Physicians with Disabilities, and Delisa and Lindenthal (2012) 9 , the two major barriers to having more persons with disabilities as medical students are the cost of accommodating those persons and medical schools’ technical standards. Persons with disabilities bring a unique perspective to the profession (Gulli, 2015) 6 . The FACCT report recommends that medical schools, “Ensure admissions processes are consistent with applicable standards of accommodation for persons with disabilities”. Curry et. al. (2020) 3 : Efforts to include people with disability as students and practitioners in the health professions have gained momentum in recent years. However, prevailing technical standards at U.S. medical schools have biases that can prevent or impede their admission, promotion, and graduation. These standards derive from an approach first promulgated in 1979 and have since remained largely unaltered. Current technical standards at most medical schools are now at odds with changes occurring since the 1990 enactment of broad civil rights protections for people with disability and current aspirations for diversity, equity, and inclusion in the medical profession. It is time to replace the technical standards construct with an approach more consistent with current medical practices, and with societal imperatives of equity and social justice. Such an approach should assess candidates’ demonstrable skills and merits, rather than relying on a preconceived construct identifying the presence or absence of defined levels of ability. The maturation of competency-based approaches to curricular design and assessment provides an opportunity to reconceptualize the abilities required to practice medicine, foster the appropriate inclusion of physicians with disability, and better align medical education and training with broader societal needs and goals. Stauffer et. al. (2022) 4 : Technical standards document US medical school's nonacademic criteria necessary for admission, persistence, and graduation and communicate the school's commitment to disability inclusion and accommodation but are considered one of the largest barriers for students with disabilities. Calls for more inclusive technical standards have increased in recent years, yet the impact of this work on changing technical standards has not been measured. The authors conducted a document analysis of 15 newly formed medical schools' technical standards to determine the availability and inclusive nature of the standards as they pertain to students with sensory and mobility disabilities. Technical standards were coded for: ease of obtaining technical standards, the school's stated willingness to provide reasonable accommodations, the origin of responsibility for accommodation request and implementation, and the school's openness to intermediaries or auxiliary aids. Of the 15 schools, 73% of the technical standards were not easy to locate online. Few (13%) included language that support disability accommodations. Most (73%) used language that was coded as 'restrictive' for students with physical or sensory disabilities. Coding of the newly accredited US MD and DO medical schools suggests that newly created technical standards are more restrictive than those in previous studies. The authors conclude that efforts to create more inclusive technical standards have not yet been realized. Newly formed US MD- and DO- granting medical schools may perpetuate historically restrictive technical standards that serve as barriers to applicants with disabilities. Future research should evaluate the role of medical school accrediting bodies to go beyond simply requiring technical standards to ensuring that the standards are readily available and appropriately convey the availability of reasonable accommodations for students with disabilities. Statistics Canada (2018) 5 : An estimated one in five Canadians (or 6.2 million) aged 15 years and over had one or more disabilities that limited them in their daily activities, according to findings from the 2017 Canadian Survey on Disability (CSD). For many of these Canadians, challenges and obstacles in their day-to-day lives may limit their full participation in society. Understanding the challenges faced by persons with disabilities in their personal, employment, or economic situations helps inform government policy. Gulli (MacLeans) (2015) 6 : In this article, disabled doctors are interviewed about their experiences. They suggest that impairment can actually facilitate better doctor-patient relationships: A disabled doctor may empathize more with patients, who, in turn, may relate to or trust a disabled doctor more because they feel understood. They 10/4/2023 9 add, “Any candidate who comes from an extraordinary background with a unique perspective, they often do make extraordinary physicians.” Battalova (2020) 7 : Students and clinicians with disabilities are underrepresented in the academic health programs and professional clinical settings. This study explored the role that clinicians’ ability to draw on their personal experiences of living with a disability have on their interactions with clients and patients. The authors identified three social pro-cesses that interact as epistemic connections are formed: understanding, advocacy, and the tensions between having a disability as a health care professional and health care settings. The results reveal that students and clinicians with disabilities consider their personal disability experiences as important factors in shaping their clinical practice. A shared experience of living with a same or similar disability facilitates a deep sense of understanding that lays a foundation for improved quality of clinician–client interaction. The concordance (same diagnosis/disability) is not the only component of understanding. The emotional connection of simply knowing what it means to navigate the world with a disability, even if specifics of the individual experiences are different is also a component of understanding. Accessible Canada Act (ACA) (2019) 8 : The Accessible Canada Act has 7 principles: 1. All persons must be treated with dignity regardless of their disabilities; 2. All persons must have the same opportunity to make for themselves the lives that they are able and wish to have regardless of their disabilities; 3. All persons must have barrier-free access to full and equal participation in society, regardless of their disabilities; 4. All persons must have meaningful options and be free to make their own choices, with support if they desire, regardless of their disabilities; 5. Laws, policies, programs, services and structures must take into account the disabilities of persons, the different ways that persons interact with their environments and the multiple and intersecting forms of marginalization and discrimination faced by persons; 6. Persons with disabilities must be involved in the development and design of laws, policies, programs, services and structures; and 7. The development and revision of accessibility standards and the making of regulations must be done with the objective of achieving the highest level of accessibility for persons with disabilities. The ACA defines “barrier” as anything - including anything physical, architectural, technological, or attitudinal, anything that is based on information or communications or anything that is the result of a policy or a practice — that hinders the full and equal participation in society of persons with an impairment, including a physical, mental, intellectual, cognitive, learning, communication or sensory impairment or a functional limitation. DeLisa et. al. (2012) 9 : Whereas people with disabilities constitute about 20% of the population, only between 2% and 10% are practicing physicians. The two major barriers to having more persons with disabilities as medical students are the cost of accommodating these persons and medical schools' technical standards. The authors offer suggestions for overcoming these barriers, and the additional barrier of communication with persons with various disabilities, such as deafness or visual impairment. The authors also discuss some of the issues involved in having greater representation of minorities in medicine. In addition, they stress the need for more training in cultural awareness for students and residents and for physicians well along in their careers. Medical educators will be increasingly called on to create new models designed to sensitize students and faculty to racial, ethnic, and other types of diversity, while documenting the efficacy and costs of extant ones, from the standpoint of both practitioner and consumer. The authors hope that the moves toward greater diversity and more training in cultural awareness will increase the efficacy of health care while reducing its cost. The demands of these efforts 10/4/2023 10 will require the commitment of diverse, intellectually capable, and compassionate people at many levels of academic medicine. CMA 2021 National Physician Health Survey (2022) 13 : The Canadian Medical Association (CMA) reports that among the 23% of physician respondents who identify as having a disability, the most prevalent disabilities include chronic long-term conditions, such as diabetes or multiple sclerosis (10%) and mental health conditions (8%). Additionally, 3% identify as having a neurodevelopment disorder (such as ADHD, autism, or dyspraxia), 2% with a hearing or speech disability, 2% with a physical mobility disability and 2% with another form of disability. Further, in comparing outcomes between those living with disabilities and those who are not, those living with disabilities have poorer mental health outcomes across all key psychological factors. They are significantly more likely to be “languishing” in their mental health (12%* vs. 6% of those not living with a disability), to be burned out (61%* vs. 39%), to screen positive for depression (62%* vs. 43%), to report having moderate or severe anxiety (36%* vs. 21%) and to report having considered suicide (lifetime) compared with those without disabilities (56%* vs. 29%). Kezar et al. (2019) 14 : The medical profession first addressed the need for technical standards (TS), defining the non-academic requirements deemed essential for participation in an educational program, in guidelines published by the Association of American Medical Colleges in 1979. Despite many changes in the practice of medicine and legal, cultural, and technological advances that afford greater opportunities for people with disabilities, the profession’s approach to TS largely has not changed over the ensuing four decades. Although physicians with disabilities bring unique perspectives to medicine and contribute to a diverse physician workforce of culturally competent practitioners, they remain underrepresented in the profession. The authors describe the need for an updated TS framework, outlining interval changes in the legal and regulatory climate, medical practice, and medical education since the initial TS guidelines were put forth. They conclude by offering eight recommendations and two functional approaches to TS that are consistent with now-prevalent competency- based medical education constructs. Further, schools should consider the principles of universal design to create policies and assessments that work for all learners, to the greatest extent possible, without the need for after- the-fact accommodations. Stergiopoulos et. al. (2018) 15 : Medical students with disabilities hold firsthand knowledge as health care recipients, yet face barriers to disclosure and support. Their experiences provide a unique lens for understanding professional identity construction; this study explored how disabled medical students experience training as both patients and trainees. Two dominant discourses emerged from the interviews and texts, revealing institutionalized notions of the perceived "good student" and "good patient." These roles held contradictory demands, demonstrating how institutions often implicitly and explicitly framed wellness as a means to optimal academic performance. Two additional themes, "identity compartmentalization" and "identity intersection," captured students' experiences navigating identities as patients and trainees. Although students lacked explicit opportunities to express their expertise as patients in the formal curriculum, their experiences in both roles led to improved communication, advocacy, and compassion. The authors conclude that institutional discourses around disability and academic performance hold material implications for curricular content, clinical teaching, and availability of supports in medical school. By repositioning students' experiences with disability as sources of expertise, this study highlights opportunities for teaching compassionate care. Stergiopoulos and Martimianakis (2023) 16 : What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. The authors explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. According to participants, dimensions of the ‘good doctor’ included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day 10/4/2023 11 interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. The authors identified two operating discourses of the ‘good doctor’: an institutionalized discourse of the ‘able doctor’ and a counter-discourse of the ‘doctor with lived experience’ which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the ‘good doctor’ carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the ‘good doctor’ based on their experiences as patients, providing important considerations for curriculum and faculty development. Reichgott (1996) 17 : Medical schools have a very low proportion of physically disabled students, which the author argues is largely a result of schools' conception of the "undifferentiated graduate" as being capable of performing the history, physical examination, and any medical procedure without an intermediary. But the author maintains that medical students need not be unblemished physically; medical educators' obligation is to educate those students who are qualified to become physicians by virtue of intelligence, professional attitude, and ability to effectively interact and communicate. With respect to clinical training, it is important to consider whether personal, hands-on experience is required for adequate learning to occur. Because most physicians limit the scopes of their practices and do not perform all procedures, because those physicians who develop physical disabilities are not precluded from continuing in some forms of medical practice, and because technologic advances allow for the substitution of imaging and diagnostic testing for the more conventional approach to the physical examination, the requirement for hands-on capability becomes less compelling. Yet not every physically disabled applicant should be admitted to medical school, and those admitted require coaching, guidance, and career advice in order to succeed with their physical limitations. The author suggests that one of the seminal concepts of medical education, "without handicap," should be seen not as referring to the pre-existing physical status of students but instead as the obligation of educators to provide all their students with the broadest possible learning experiences so that they will be without the handicap of inadequate education when they proceed to their chosen fields. Jain et. al.(2022) 18 : Medical education programs profess commitments to justice, equity, and inclusion, seeking to diversify the profession and better serve patient populations. Although disability has more recently joined recognized categories of valued diversity, significant barriers remain for disabled learners in medicine. This paper develops the concept of the capability imperative, derived from a constructivist grounded theory study examining disability inclusion at four U.S. medical schools that analyzed technical standards policies and interviews with 19 disabled students and 27 school officials (faculty and administrators). Through three motifs (the selfless superhuman; the "real world" of medicine; and the malleable student), the capability imperative enforces the characteristics of a good physician, justifies institutional arrangements, and seeks to produce a learner who can conform to these expectations. Drawing on critical disability theories of ableism and crip theory, this paper argues that the capability imperative represents a context-specific manifestation of ableism that upholds a cultural logic of compulsory hyper-ablebodiedness and mindedness. This logic is antithetical to inclusive goals. Exploration of what constitutes a physician and whom this vision serves may help to shift the professional culture towards justice and unroot disabled peoples' ongoing marginalization in the medical profession. Mace Basic Principles of Universal Design (1990) 20 : In 1997, Ronald Mace led a working group of architects, product designers, engineers, and environmental design researchers, to create the 7 principles of universal design to help guide the design process of environments, products and communications. Summary of the principles. • Principle 1: Equitable Use. The design is useful and marketable to people with diverse abilities. • Principle 2: Flexibility in Use. The design accommodates a wide range of individual preferences and abilities. 10/4/2023 12 • Principle 3: Simple and Intuitive Use. Use of the design is easy to understand, regardless of the user's experience, knowledge, language skills, or current concentration level. • Principle 4: Perceptible Information. The design communicates necessary information effectively to the user, regardless of ambient conditions or the user's sensory abilities. • Principle 5: Tolerance for Error. The design minimizes hazards and the adverse consequences of accidental or unintended actions. • Principle 6: Low Physical Effort. The design can be used efficiently and comfortably and with a minimum of fatigue. • Principle 7: Size and Space for Approach and Use. Appropriate size and space is provided for approach, reach, manipulation, and use regardless of user's body size, posture, or mobility. 10/4/2023 13 XI.References 1. Meeks LM, Neal-Boylan L. Disability as Diversity. In: Meeks LM, Neal-Boylan L, eds. Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing, and the Health Professions. Springer International Publishing; 2020:C1-C1. 2. Postl B AM, Ding M, Ellaway R, Hammond R, Hanson M, Lewis M, Mankour H, O’Hearn S, Parsons W, Prowse O, Razack S, Richardson L, Sanfilippo T, Smith P, Sharma r, Tardiff M, Verma S, Moineau G, Karwowska A, Kimball J, Shahin M, Drake C. . The Future of Admissions in Canada Think Tank (FACTT) Proposed Strategy for Enhancing Admissions. Report. 2020. April 22, 2020. https://www.afmc.ca/wp-content/uploads/2022/10/2020- 04-22-FACTT-strategy_en.pdf 3. Curry RH, Meeks LM, Iezzoni LI. Beyond Technical Standards: A Competency-Based Framework for Access and Inclusion in Medical Education. Academic Medicine. 2020;95(12S):S109-S112. doi:10.1097/acm.0000000000003686 4. Stauffer C, Case B, Moreland CJ, Meeks LM. Technical Standards from Newly Established Medical Schools: A Review of Disability Inclusive Practices. J Med Educ Curric Dev. Jan-Dec 2022;9:23821205211072763. doi:10.1177/23821205211072763 5. Canadian Survey on Disability, 2017. Statistics Canada. 2018. https://www150.statcan.gc.ca/n1/daily- quotidien/181128/dq181128a-eng.htm 6. Gulli D. Diversity among doctors: Students with disabilities are finding their place in medical schools— and beyond. MacLeans. 2015;doi:https://macleans.ca/education/post-graduate/breaking-down-barriers-for- med-students-with-disabilities/ 7. Battalova A, Bulk L, Nimmon L, et al. “I Can Understand Where They’re Coming From”: How Clinicians’ Disability Experiences Shape Their Interaction With Clients. Qualitative Health Research. 2020/11/01 2020;30(13):2064-2076. doi:10.1177/1049732320922193 8. Accessible Canada Act - 2019. Government of Canada. Accessed 6 August 2023, https://laws- lois.justice.gc.ca/eng/acts/A-0.6/ 9. DeLisa JA, Lindenthal JJ. Commentary: reflections on diversity and inclusion in medical education. Acad Med. Nov 2012;87(11):1461-3. doi:10.1097/ACM.0b013e31826b048c 10. World Health Organization International classification of functioning, disability and health: ICF. 2001. https://apps.who.int/iris/handle/10665/42407 11. Ferro-Lusk M, Meeks LM. Chapter 4: The Process for Determining Accommodations. Equal Access. 2nd Edition ed. Springer Publishing; 2021. 12. Bulk LY. Being blind and belonging in academia. Thesis: Text, Sound. 2020. https://open.library.ubc.ca/collections/24/items/1.0395453 13. CMA 2021 National Physician Health Survey. 2022. https://www.cma.ca/sites/default/files/2022- 08/NPHS_final_report_EN.pdf 14. Kezar LB, Kirschner KL, Clinchot DM, Laird-Metke E, Zazove P, Curry RH. Leading Practices and Future Directions for Technical Standards in Medical Education. Academic Medicine. 2019;94(4):520-527. doi:10.1097/acm.0000000000002517 15. Stergiopoulos E, Fernando O, Martimianakis MA. "Being on Both Sides": Canadian Medical Students' Experiences With Disability, the Hidden Curriculum, and Professional Identity Construction. Acad Med. 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Center for Accessible Housing, North Carolina State University Raleigh, NC; 1990. 10/4/2023 15 XII. Working Group Members Dr. Cheryl Holmes, Associate Dean, Undergraduate Medical Education (UGME), University of British Columbia Dr. Laura Farrell, Associate Dean, Student Affairs, University of British Columbia Dr. Ginger Rudy, Assistant Dean, Student Affairs, University of Saskatchewan Dr. Laura Yvonne Bulk, Assistant Professor Teaching, Occupational Science & Occupational Therapy, University of British Columbia Dr. Lynn Ashdown, Board member Canadian Association of Physicians with Disabilities (CAPD) & Investigator- Equity and Health Systems Lab, Patient partner-Lead Advisor to the AFMC Dr. Quinten Clarke, Vice-President, Canadian Association of Physicians with Disabilities (CAPD) Dr. Franco Rizzuti, Public Health & Preventative Medicine, University of Calgary & President, Canadian Association of Physicians with Disabilities (CAPD) Dr. Lee Toner, Associate Dean, Undergraduate Medical Education, Northern Ontario School of Medicine (NOSM) University Dr. Alex Scott, Head, UBC Department of Physical Therapy, University of British Columbia Dr. George Kim, Associate Dean, Admissions, Schulich School of Medicine & Dentistry, Western University Dr. Julia Ersilia Hanes, Resident, Physical Medicine and Rehabilitation, University of British Columbia Charles Su, Interim Vice-Dean, Undergraduate Medical Education, University of Ottawa Rachel Giddings, UBC Student, Class of 2026 Lisa Graves, Secretary, Committee on Accreditation of Canadian Medical Schools (CACMS) Melissa Shahin, Chief Operating Officer and Lead, Social Accountability, The Association of Faculties of Medicine of Canada Dr. Saleem Razack, Professor, Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of British Columbia Dr. Michael Quon, Division of General Internal Medicine, The Ottawa Hospital Dr. Erene Stergiopoulos, Clinician Scientist, Department of Psychiatry, University of Toronto Special thanks to Kacey Krenn LLB, and Meredith Holmes LLB– for lending their legal expertise. 10/4/2023 16 XIII.Appendix 1: Legislation Pertaining to Persons with Disabilities Legal Requirements: What are the legal obligations that each provincial act imposes on the university/medical school in regards to accessibility for people with disabilities? The legal obligations of the university and its faculty of medicine are nuanced, depending on the specific facts of each circumstance. Broadly the ideal principles are as follows: 1. Medical Schools must develop and implement accessibility standards and regulations with the goal of achieving the highest level of accessibility. 2. Medical Schools should consider revisit and modify its policies which are ablistic. 3. Medical Schools must be unbiased towards students, staff, the public and patients. This requires the school to educate their decision-makers on what accessibility standards are, understand how they may fail to accommodate people with disabilities, actively and continuously seek out ways to accommodate people with disabilities, act in good faith when working with people with disabilities, and investigate and stop their decision-makers who are prejudicing or stereotyping people with disabilities. 4. Medical schools have a duty to inquire where it is reasonable to believe, based on observation, that the individual may be suffering from a disability or medical condition that is affecting their performance or behavior. It is therefore prudent to make inquiries as to whether there is a medical issue that is affecting their performance or behaviour and allow them the opportunity to obtain medical information. If they fail to do so, or there is no medical condition, then there is no duty to accommodate. If they do provide medical information in support of a medical issue or disability, then there will be a duty to accommodate. 5. Medical schools must collaborate with people with disabilities and organisations who provide assistance and education to people with disabilities. CCSM c H175 | The Human Rights Code. (n.d.). CanLII. Retrieved May 4, 2023, from https://www.canlii.org/en/mb/laws/stat/ccsm-c-h175/latest/ccsm-c- h175.html?searchUrlHash=AAAAAQBhKCJwb3N0LXNlY29uZGFyeSIgT1IgInBvc3Qgc2Vjb25kYXJ5IiBPUiAibWVkaW NhbCBzY2hvb2wiIE9SIHVuaXZlcnNpdHkpIEFORCBkaXNhYiogQU5EIGFjY2Vzc2liKgAAAAAB&resultIndex=28 CQLR c C-12 | Charter of Human Rights and Freedoms. (n.d.). CanLII. Retrieved May 8, 20