Jamie, let me get all set up here once again. Okay. Well, thank you everyone for joining us today. It is so nice to see all of you here exploring PM&R and I'm especially excited that you're joining us for the session on disability and physician bias. My name is Dorothy Tulchin. I'm the Director of Medical Student Education for the Department of PM&R at Spaulding Rehab Hospital and Mass General and Harvard Medical School and also oversee our medical school's integrated disability and anti-ableism curriculum. So during this talk and after, any of you who'd like to talk more about disability or any other topics in PM&R, please feel free to reach out to me anytime and I'm always happy to set up a time to chat. So as you have undoubtedly been seeing over the course of your exploration of PM&R, physiatrists routinely care for patients living with disabilities of all types and utilize a toolkit of pharmacologic, procedural equipment and interprofessional collaborative strategies to deliver comprehensive care. We're going to extend that conversation here to thinking about the role and privilege that physiatrists have in providing comprehensive clinical care, advocating for inclusive, accessible care and educating our healthcare colleagues about the ongoing needs of individuals with disabilities in the healthcare setting. In this section, we'll explore the ongoing impact of physician bias on care for patients with disabilities and the role for physiatrists and really all clinicians as disability advocates and educators. So individuals living with disability comprise the largest minority population in the United States. It's over a quarter of the population and also in the world at over 1 billion people. A person can enter the realm of disability at any time. Disability can be apparent or non-apparent, temporary, fluctuating or permanent. Individuals living with disability can and do simultaneously hold all other intersecting racial, gender and other marginalized identities. People living with disabilities are part of all levels of the healthcare system from patient to clinician. So sort of heterogeneous population, people with disabilities includes individuals with physical, sensory, cognitive, intellectual, developmental, communication disabilities. And when we include mental health conditions and chronic illness in the disability umbrella, the number grows. In our society and around the world, disability is often associated with assumptions and stigma that limit an individual's equitable inclusion and participation. This is slowly changing for the better, but disparities persist, including within the healthcare system. So here's where we've come from and where we need to be in terms of healthcare for people with disabilities. So historically in the healthcare system, disability was really seen as a problem to be fixed or cured. Disability was associated with a life less valuable, a failure of the medical profession in some way. This resulted in clinicians being unable to see past disability, embracing the belief that because individuals with disabilities were not functioning normally, they required care providers and clinicians to make decisions for them. So this resulted in perpetuated stigma, institutionalization, and really the systemic acceptance of substandard care for patients with disabilities. Now, over time in the United States, due to a robust civil rights movement, landmark bipartisan legislation centering on access and equity, and then international attention to the human rights of persons living with disabilities, there's been a gradual shift in attitudes and inclusion, as well as a frameshift within healthcare. And we're shifting to focus not on disability as personal failure, but rather that a spectrum of function arises from the interactions among person, environment, and society. And one formulation of this you can see on the screen is the biopsychosocial model of disability. So this destigmatized and inclusive approach to disability helps us better envision a future in which people with disabilities routinely receive equitable healthcare. We neither refuse to treat nor only partially treat a person on the basis of disability. We provide reasonable accommodations and appropriate communication. We respect the personhood and autonomy of each individual. We support and encourage health promotion and community participation for all of our patients. And we recognize that clinicians have disabilities too, both apparent and non-apparent and are welcome in our profession. And with this vision in mind, this is when gaps in access and outcomes of healthcare begin to close. But we're not there yet. So disability, as I mentioned, is the largest minority group in the United States and the world. People living with disabilities experience ongoing disparities in access to, experiences within, and outcomes of healthcare. Inadequate education for clinicians contributes to persistent healthcare disparities. Fewer than half of practicing clinicians report being very confident in their ability to provide the same quality of medical care for patients with disabilities as those without. And physicians need to be agents of change who can confidently provide accessible, comprehensive care for all patients. So what are some of the disparities that exist? Excuse me. So worldwide, this is data from the World Health Organization. People with disabilities have the same general healthcare needs as others, but they are twice as likely to find healthcare providers skills and facilities inadequate. Excuse me. Three times more likely to be denied healthcare. Four times more likely to be treated badly in the healthcare system. This is worldwide data, but if we look at our own country as well, despite frequent interactions in the healthcare system, people living with disabilities tend to be less healthy than individuals without disabilities, although they do not inherently need to be. So in our own country, people with disabilities are more likely to have chronic health conditions and to engage in unhealthy behaviors such as smoking. They're also less likely to engage in recreational physical activity. According to the CDC, nearly half of adults with disabilities get no aerobic physical activity at all. And having a disability is associated with higher rates of some kinds of cancers with slayed diagnoses. Having a disability has also been associated with increased risks from COVID-19. And the pandemic has really shown a spotlight on the disparities in care for patients with disabilities. It is also relevant to us that inequities in healthcare begin outside of the healthcare setting. Structures and practices in our society result in people with disabilities fearing worse in key social determinants of health. So people living with disabilities tend to be less educated, underemployed, earn less money, and more likely to live in poverty than counterparts who do not happen to be living with disability. And the impact of disability on healthcare access and outcomes is exacerbated by the existence of intersecting racial, gender, and other identities. So what are some examples of ongoing inequities within the clinical encounter? Lower rates of complete physical examinations. Lower rates of screening for abuse and neglect despite people with disabilities having higher rates of both. Incomplete or delayed preventive care. Incomplete clinical investigation due to inaccurate attribution of symptoms to a disability. This is called diagnostic overshadowing. So why do disparities in access to care, clinical encounters, and outcomes persist? There are a number of barriers to individuals living with disabilities obtaining accessible, equitable healthcare. So, physical. Sometimes patients can't find accessible practices. Sometimes they don't find out until they arrive at an office or a building, but they can't, for example, get into the building. And even if they can get into the building, they can't transfer to a high-risk facility or a high, non-adjustable exam table. Communication. This can be a barrier from the level of making an appointment to making decisions within an appointment, to following up. Often resources are unavailable in an appropriate format or level, or even in the patient's appropriate language. American Sign Language is a great example that translation services are not always available everywhere or are not requested and advanced by a clinician. And a patient shows up in the office and there's a communication barrier. Systemic. So, one in three adults with a disability in this country has an unmet healthcare need within the past year due to cost alone. So, the high cost of healthcare in itself contributes to disparities in healthcare for people with disabilities. And then, programmatically. So, people with disabilities have not historically been pictured on ads for health promotion, like exercise, smoking cessation, and the like. And this lack of stakeholder involvement results in lack of resonance and lower rates of complying with and addressing healthcare imperatives. And then, there's clinician-level barriers. These include, as you can see on the screen, inaccurate assumptions about patients and their needs. Overattending to disability. Within a clinical encounter, the patient comes in for something unrelated to disability, but the clinician is focused on a patient's piece of mobility equipment, for example. Underattending to disability or insensitivity to the consequences of disability. Being unsure about how to talk to a patient about a wheelchair and saying, okay, I'm not even gonna go there, for example. However, when in fact, the disability is relevant to the patient's presenting concern or other concerns. Lack of knowledge, skills, and confidence. So, on standardized clinical exams, medical students are less likely to order appropriate tests and provide lifestyle counseling when interacting with standardized patients with disabilities. And when we think about how we are going to educate our current generation of physicians, and I'm hoping that many of you as medical students have had some disability education within your curricula. Disability education is gradually being integrated more and more robustly across schools in our country. But when we think about who our mentors are for ourselves and for our students, many of the practicing faculty today did not have disability education themselves. And so, our students, you guys, are moving into a clinical space where you might need to be advocates and agents of change. And so, you might not know as much about disability as you do. So, to me, the need for students to learn clinical skills and be empowered to advocate on behalf of patients with disabilities is a little bit of a call to action for physiatrists, for students to become physiatrists, to become active in the space of disability advocacy, learning more about disability bias and how we mitigate it. And for us to use the knowledge and experience we gain in physiatry to even further inform our advocacy efforts. So, as you know, from its inception as a field, physiatry has been intimately connected with ensuring not only comprehensive care for individuals with disabilities, not just the clinical care part, but also broader access to society and to social justice. And the work that physiatrists have done in advocating for passage of the Americans with Disabilities Act, for example, involvement in initiating and implementing change in the independent living movement, as other examples. What else do I wanna say about physiatrists? So, physiatrists focus on function, independence, and quality of life. And it really grounds us in a commitment to ensuring that our patients with disabilities are able to experience their homes, their communities, and their day-to-day life as smoothly and as fairly as their non-disabled counterparts. And so when you train in physiatry, you become very familiar with providing for the unique needs of patients with disabilities, to listening to your patients as the most important source of information about their needs, and really positions us to connect with communities and connect with and educate our colleagues as part of the wider team that will take care of and promote the health of our patients. I think I'm gonna be redundant on this slide. I guess I'm very excited about the role of physiatrists as champions for advocating for and implementing disability care and disability education as well. By virtue of our clinical expertise, we can focus on function and understanding of the impact of community engagement on overall health, and our connections to stakeholders can also advise and teach. And there are many other ways that as a physiatrist and even a physiatry trainee that you can contribute to disability advocacy and also to disability education for students and peers. But you don't have to be a physiatrist to be a disability advocate. So while physiatry is a natural home for disability advocacy, you likely already are on your way to or have been engaging in disability advocacy by virtue of your just being here and your interest. So I wanna just share a couple, four opportunities for addressing and mitigating physician bias through positive behaviors. So the first one is, be really thoughtful about how you choose your language. So language forms the backbone of how we think, what we say directly influences the way that those around us understand concepts and ideas. And that's why it's really important to be very thoughtful and considerate in your language as a clinician and really as a role model for those around you. So we talk about first person language, or person first language. Person first language puts a person before their diagnosis, describing what a person has or lives with rather than asserting what a person is intrinsically. So it avoids defining someone by their disability and instead emphasizes their humanity. So you can see in this slide, humanity over disability, it's an individual with a disability or an individual living with a disability versus a disabled person. Now, we recommend that this be our default, but most important is to ask a person how they identify and what their relationship is with their disability and what their preferred language is. So some people prefer identity first language. Identity first language puts the descriptor first and recognizes disability as an intrinsic part of a person's lived experience. There are a couple of specific disability communities where this preference is more common. So one example is in the deaf community where deaf person is generally preferred over person with deafness. And again, this positions disability as an identity category, something that is embraced, describes membership within a cultural or social group and is a central aspect of an individual's identity. So the bottom line is ask people what their preferences are. But if you're not sure, it's often wise to start off with person first language. So here's sort of a visual representation of the difference between identity first and person first language. This shows the example of autism, which is another community where autistic person is often preferred over person with autism. One more point I will add here is to think about other subtle ways in which can contribute to negative stereotypes around disability. So we're talking about, you know, we say this is a person with a disability, a person living with a disability. We can say experiencing a disability and we prefer these terms to other descriptors like this is a person suffering from paralysis or this is a person afflicted with deafness, for example. Both are examples which I've seen in the not too distant past in written documentation. Another piece here while we're talking about language is that historically doctors have used the R word, the word retarded to refer to people who have intellectual and developmental disabilities. This R word has caused incredible stigma and discrimination and harm to patients and families. Even though the R word might still show up in older textbooks, the modern preference is not to use the R word and to use intellectual and developmental disability or developmental delay. We're also all human. So there's a lot to consider when we think about the language choices that we do make and the multiple identities that our patients hold, disability just being one of them. It's understandable to make mistakes and to use language that might be hurtful or incorrect unintentionally. In these circumstances, it's important to avoid over-apology that really places the emphasis on the incorrect language, but instead to acknowledge a mistake and move on with an understanding that you'll do better next time and that you respect the person's preferences. So sometimes a person might call you out on it saying, please don't do that. Or if you're not sure and you've used a certain language or framing, it's okay to say to a patient, I just used this language. Is this okay for you? I wanna make sure that we're using the language that you best identify with and that's all okay. So moving on to language used in clinical encounters. So often you will be giving a one-line description of the patient that you've seen in clinic or in the inpatient setting to help your team understand sort of who's in front of them and what the presenting concern is in that moment. It's important when you're framing this one-liner to make sure that you're using disability descriptors in really precise and relevant ways. When we use disability descriptors that are not related to the presenting symptoms it's not necessary for clinical reasoning or maybe important to say because our patient might need accommodations that we have to make sure the patient gets now. And we're just saying, oh, this is a wheelchair-bound person who's here with a sore throat, for example. Is it necessary to frame this patient solely in the terms of their mobility equipment? And wheelchair-bound we'll talk about also is a specifically non-preferred term. But when we use disability descriptors that aren't really needed, we're not looking specifically for inaccurate assumptions about a patient's competence and quality of life. We know that regardless of disability type, clinicians make quick, often implicit assumptions about what a person is able to do or not do, and especially about what decisions they may be able to make or not make. And often these assumptions are incorrect and they undermine a patient's autonomy. So we wanna avoid the opportunity for applying those kinds of assumptions. When we use disability descriptors when they're not necessary, they can reinforce the practice of diagnostic overshadowing like we talked about before, premature closure. Oh, this patient has, trying to think of a good example as we're chatting. Well, a common example that we actually talk about when we talk about diagnostic overshadowing with our first-year medical and dental students is autism. So think about a patient, an autistic patient who may be nonverbal, communicates in gestural or other verbal forms. They, how do I wanna frame this? Imagine that the family comes in and they say to their clinician, you know what, our child is not behaving the way they normally do. We think something is wrong. Something doesn't seem right. They're making vocalizations they don't usually make or they've changed their behavior in a way that's really atypical. Commonly a clinician will say, oh, that child is autistic. Non-vocal verbalizations are normal. There's nothing wrong. This is an example of diagnostic overshadowing where this would have provided, should have provided an opportunity for the clinician to say, okay, what is different? What else might've been going on for this patient? And ask classic medical questions. Does the patient have a fever? Does the patient, is there any evidence of abdominal pain? Let's do an exam. And oftentimes diagnoses that are medical and sometimes urgently surgical are missed in the context of this diagnostic overshadowing. The other concern about using disability descriptors that may not be necessary in a one-liner is that they may undermine care by triggering insecurity among clinicians, right? So we know that clinicians tend to be not so confident in caring for patients with disabilities. So as soon as we need disability, we might trigger that insecurity and result in the patient stepping back or the clinician stepping back and limiting their communication and connection with the patient. So here are a couple of examples of one-liners. And we can think about what kind of picture they paint of our patients. So the first one is an unfortunate 56-year-old wheelchair-bound man with weight loss. So what image does that bring up for us, right? What all we know so far about this patient is that something is very sad. This patient is bound or limited to some device. They are not independent. And we know a little bit about the weight loss, but the presenting medical concern is only a fraction of that description. We think about then a 56-year-old man with weight loss, then what do we think? We're like, this is a middle-aged person, weight loss. We know that weight loss can sometimes suggest that maybe there's an oncologic diagnosis, so we need to start a workup. Sends you down a pretty different path. Now, there's maybe that the wheelchair may be relevant. So you might say something then like, this is a 56-year-old man with weight loss who uses a wheelchair, so we will need a wheelchair accessible scale, right? So then the relevant issue relating to the disability in this case right now is the wheelchair. And we can address the wheelchair and we need to as an accommodation, but it's not the focus of our medical encounter. So opportunity number two, to mitigate bias and to optimize clinical care. I wanna go back to the biopsychosocial and delve into this a little bit more. So the biopsychosocial model is the model we teach at Harvard Medical School and that our interprofessional colleagues use as well. And so using this model and approach to disability fosters interprofessional collaboration and also ensures that we take a patient-centered approach. You'll notice that the word disability is not really even going to show up here. So the International Classification of Functioning, Disability and Health is the WHO approach to thinking about function and disability and really asks and helps us address the question, how well do people function in their physical, built, attitudinal and social environments? It looks something like this, showing us that all the facets of life are sort of interrelated. So a person may have a health condition. That health condition may affect a body structure or a function that's called an impairment. If in turn that impairment prevents a person from participating in activities, we call that a participation limitation. And then if because of that limitation, a person can't participate in broader life activities or in social connections, things like that, then it's called a participation restriction. So let me give you an example. So a health condition may be heart failure. The impairment of the body structure, right, is that the heart is not working. So there is reduced physiologic exercise capacity. In turn, the activity limitation is that the patient may be unable to walk or bike because they're limited by shortness of breath. The participation restriction then is because the patient cannot walk or bike, they then cannot go out and cycle with their friends. They may not be able to access healthcare as easily because they can't get all the way to the bus stop to take the bus to the hospital. So when we break down a person's lived experience in this way, we can target opportunities to intervene to help optimize the patient's function. So rather than saying, well, this is a patient with heart failure who's unfortunately just sitting at home and they're not doing things, we say, well, this person with heart failure, we can try to ameliorate the heart failure the best we can from a medical perspective, right, and address the impairment. But when we can't, let's look at their activity limitation. They're unable to walk or bike. So here we could say, well, is this person a candidate for some kind of mobility device to help them conserve energy and to help extend the distance that they can traverse? Then the next question, so say we can get this patient a wheelchair, for example, right? We might actually be able to make that activity limitation go away. Then they're free to walk or if an adaptive bike is appropriate, then we can get them out biking. The next question is a participation restriction. So say we give this patient a wheelchair, they no longer have to walk long distances. They can use their wheelchair. Then they can access public transportation, for example, or they get an accessible van if they're able to. Then they can go out and spend time with their friends or be able to get to healthcare environments. So we may have ameliorated the participation restriction, but in some cases we may not have. So say we ameliorate the activity limitation. So unable to walk, get the patient a wheelchair. Say that they have a manual wheelchair and they still can't traverse very long distances using the manual wheelchair. So they still can't get out to see their friends. They still can't access healthcare. So then we say, all right, we still have this participation restriction to deal with. So what else do we need to put in place? Maybe we need to help engage the patient with accessible transit services. Maybe we need to talk to the patient about other community resources, or are there ways that resources can come to the patient in their home? Are there other folks who have had a similar situation in their community and how have they addressed it and can we troubleshoot and learn from each other? So a helpful model in helping engage our patients in autonomous and independent lives. Opportunity number three, practice disability humility. So practicing disability humility is recognizing that people with disabilities and their families are the experts in their own experiences and we can elevate their voices. So we recognize that those who do not have a disability or even have the same disability, but they have a different lived experience, of course, because every individual is different, that any individual will always only have a partial understanding of another person's lived disability experience and operating from that position. So it's important that we advocate on behalf of our patients, that we adapt our clinical approach to ensure accessible and equitable care for all patients, that we screen for disability and complications of types of disability and we better communicate with patients about their disability. Ask them to help us understand their lived experience, what works well and what is not working well and where we can partner with them and troubleshoot to help improve their experience with healthcare and beyond. Our ability to understand the perspectives of individuals living with disabilities and chronic health conditions really begins with communication. We need to reach out and understand. Some individuals living with disability and chronic health conditions have chosen to help be educators. We cannot expect any person just by virtue of happening to have a disability or chronic health condition to be the educator per se, but we can create environments where people can choose to educate from their lived experiences. So this is me, a group of Harvard medical students created this photo narrative exhibit in celebration of the 30th anniversary of the ADA a couple of years ago by bringing together narratives of individuals with disabilities and chronic health conditions and to showcase their experiences around and within healthcare. So if you want to look at this more, you can go to our website. It's called This Is Me. You can Google This Is Me and Mass General Hospital, and it should bring you to the page where you can see the photographs and the stories that the students collated in their longer forms. And this is important for us to look at the stories and to enlighten us about the fact that disability is all around us. There's no one way that disability looks or is experienced and that disability affects not just our patients, but also our coworkers, our teachers, in this exhibit are highlighted, medical students living with disability, clinicians living with disability, hospital staff living with disability, community members and advocates living with disability, caregivers for patients living with disability, and the individuals, the range of intersecting identities. Here are some examples. So this is King. He is a HMS student and he says, a diagnosis is not just a diagnosis. There's a story behind it. I envision a healthcare system and medicine to be a world where we're seen as human beings first. And then he elaborates and you can read more about his perspective in the exhibit. This is Michael. Michael is a health policy lawyer. I did not go to law school to be a disability rights advocate. It was only after considering how I had been excluded and thinking about how the world should be made better that I got involved. So the last opportunity I will share here for mitigating bias and its impact in all clinical settings that you are gonna be operating in and have been operating in is thinking about ableism. So ableism is disability-based discrimination. It results from our perception of able-bodied as normal and superior to those who are differently able or perceived as differently able. Ableism can be explicit or implicit, similar to other forms of discrimination. Ableism is directly and can be indirectly harmful as well. Individuals might experience ableism as anything from microaggressions and language use to outward violence and the impact of certain implicit beliefs that just make it difficult to succeed in a different space. So for example, a medical student living with a mobility disability who is asked to run up and down stairs in order to round on patients, for example, it makes it very hard for that student to take care of patients and to succeed. Ableism impacts the way we design our environments and our policies and the ways we interact with one another. So we saw the impact of ableism on the development of policy, particularly during COVID when policies were being put in place to anticipate potential ventilator triage scenarios. Ableism sort of comes out in the accessibility or non-accessibility of our hospitals and clinical spaces. Around your clinical spaces, do you see a wheelchair adjustable scale, for example, or do your clinics have height adjustable exam tables? Clinical sites are required to have this equipment. Not every clinical room is required to have accessible equipment, but accessible equipment does need to be available should patients need it. So sometimes this equipment, your clinical staff doesn't know that it exists, but often it is there somewhere. But there are sometimes clinical settings where the equipment actually is not there. And a medical student can ask questions honestly and curiously about where the equipment is. How can we get it? If our clinic doesn't have it, is there a way that we can order it and ensure that when our patients come and they need an adjustable height exam table that we have one available, so we can lower the height and patient can transfer more easily to their wheelchair, for example. So with that long commentary there, I wanna hear from you about thoughts or questions you have, have a case we can walk through, but I kind of wanna hear from you. Feel free to put questions in the chat box, or you can unmute and ask questions directly with Dr. Tolchin if you would like. Hi, thank you so much for your talk and just this focus on this really important topic. I was wondering if you could comment on there's definitely a dearth of physicians with disabilities as well, particularly focusing on, like, that there's over 20% of the US population with disability, but less than 1% of medical students. And then from that, even fewer going on to be physicians. And I was wondering what your thoughts are to make both the medical school environment and then also residency more disability friendly, just so that we're creating a more diverse population of physicians to care for our patients, which, as you said, a lot of them have disabilities as well. Thank you so much for posing that question is extremely important in the context of this conversation about disability and medicine. 100% and we know that physician patient concordance along multiple axes improves patient care. So it's important that our workforce does reflect to the greatest extent possible the lived experiences within our society. Having clinicians with disabilities as part of our workforce also emphasizes the importance of an anti ableist learning and practice environment and that has multiple downstream implications as well. What can we do to improve the inclusion of people with disabilities in the clinician workforce. We should talk about first sort of some of the reasons why we don't currently have as high of a proportion of people with disabilities in our workforce, as we would like. There's a few reasons for this, we can talk about college. It's a much bigger conversation but there are a couple of really key important reasons to touch on here. The first one is physician bias about disability there, the stigma and the risk of disclosing disability historically has been high for clinicians that no disclosing disability could potentially result in loss of opportunities to be considered for clinical training and other opportunities so there was some fear around disclosure and what that might mean and how students and clinicians would be judged. And that is gradually changing for the better. But some of that flavor and fear still exists for a lot of our, a lot of our clinicians. The second piece is technical standards of medical schools. So medical schools, each develop their sort of expectations about what a medical student can and should be able to do. And sometimes that language has felt exclusive for students with certain types of disabilities and so it is easy to feel like perhaps a student won't fit in in medical school and I think this prevents a lot of potential medical students or pre meds from applying in the first place so I think that has been a historical barrier as well. So what can we do to, to change this and improve and enhance the pipeline of students with disabilities going into medicine, to your point of going into medical school and then continuing on to residency and then launching from residency into into faculty positions. So the first piece is explicitly creating an open and supportive and well resourced environment for medical students to come into. So, from an institutional perspective, medical schools have available on their websites information about accessibility, medical schools hire disability resource providers to play the role of supporting students with disabilities and make that person well known to anybody looking in at that medical school so a student with disability knows that there is a role for and welcoming of students with disabilities and make good on those resources. So I think that's the first piece is that we need to be more welcoming and talking about clinical care for patients with disabilities, although a separate issue is just as important. Sorry it's a little bit noisy. It's just as important. We found at Harvard Medical School, four years ago when we started explicitly adding clinical disability content into our curriculum, we found that talking about patient care opened up an environment for students to start talking more about their own personal experiences with disabilities, and they came and said, Oh, Dr. Tolton you're talking about disability in a way that resonates with me I wanted to share an experience that I have had personally. And since we started talking about disability clinical care. We have since built a robust and growing disability identity and affinity group we've built in a mentorship structure so that our students have guided mentorship from living with disability and chronic illness themselves to talk about what the process is like. And so there's some guidance about what kind of accommodations Can I ask for who should I ask when should I ask, what should I consider if I'm considering disclosure, and what are the implications for that. What have been your paths for success. So, the bigger picture I think is creating environments where conversation is welcome and acceptable and and an acknowledgement that we're not going to have all the answers on how to do accommodations exactly right, but if faculty and institutions commit to the process of working to do it well we will all learn together and have more open environments. And I think that's kind of where we need to go. Okay, so we have had a couple questions submitted in the chat box. The first one is from Austin and so thank you for such helpful information in the description of ableism. What is meant by perceived disabilities, can you expand on that a little bit. Yeah, great question. So, it's interesting actually in the Americans with Disabilities Act definition of disability refers to a person who currently has a functional impairment has a history of having a functional impairment or is perceived as having functional impairment so some of that comes from there. So, it is possible, and it's possible is the case that some people who live with certain diagnoses or certain experiences do not consider themselves to have a disability but another person looking at them might say, Oh, that person has a disability. And so we think about the implications of ableism, the, the biases and the behaviors that arise from the possibility that a person has a disability is ableist, even though the person who, who might experience the behavior might be the trigger for the paper it might might not identify as having a disability. That's sort of where we're going with that. Is that clear are there other questions. So we do have some other questions. There was one. You mentioned in the beginning about disability education, I was wondering if you could elaborate on how disability education is being taught in medical education and how it can be improved. I just finished my first year and I haven't had much education in that front. Awesome. I smile because Amy knows that I'd be happy to give three other hours of lecture about this so I was trying to to minimize. I'm very happy and I'm glad that you asked. I don't want to overpower this this talk with that. So it is a great question. So, disability education in medical school today is very heterogeneous in terms of its availability, the kind of content that's covered. The depth of content is that is covered, and the way that the content if it's provided is provided. So, just over 50% of schools, sort of specifically acknowledge that they provide disability education at all. And within those 50% often disability education occurs as a one time lecture or a one time panel that students haven't in any of a given number of courses without substantial follow up or advancement of clinical skills. So we do have a long way to go in terms of disability education on a national on a national scale. There have been efforts toward developing know disability competencies so that we could sort of unify the goals that we're teaching for putting together repositories or databases of different disability education intervention so that schools have pieces to choose from. One challenge is that medical school curricula and structure and changes to medical school curriculum and structure are very school dependent so it is very hard to institute education that's really going to be uniform across every school, despite knowing that as a workforce, all graduating medical students need to be able to confidently interact with and take care of a patient who happens to have a disability. And there are increasing numbers of faculty who are very committed to disability education I can tell you, compare you know, looking 20 years ago to looking now is a dramatic difference in recognition of the importance of disability education so I think that is very promising. Physiatrists are leading a lot of the way in disability education. Again, as I said a little before, but really by virtue of having so much patient experience, and being able to really advocate through the patient voice being able to bring in patients who can speak to the disability experience particularly in healthcare into the medical education setting so long way to go. I at Harvard Medical School, about four years ago, a team of about 20 students and I went through the entire curriculum and identified where disability was sort of being mentioned, where there were places that seemed like would be a really good place to disability lens to the conversation and places where there just seemed like gaps that we just needed to to address disability head on. We developed relationships with all of our course directors and have been able to build in and implement a longitudinal disability curriculum across the students, full medical school experience that gradually advances their ability to think about reflect and actually build and practice their clinical skills. And it has been really fun really important has had an important impact on our patients. And I think one of the biggest lessons has been about the importance of thoughtful advocacy, like we really had to make the case about why it is important. So that is a really important first step if you're interested in disability advocacy or enhancing disability and curriculum, learn a lot about what are the statistics about people with disability, how are people with disabilities treated in healthcare. How does a person with disability navigate your healthcare system. And then you can ask the question, are we preparing our students to fully take care of people with disabilities in our own system and if we're not, how can we work together to make change. And folks at our school have been very receptive to working together in that frame so I'm happy to share that experience also happy to talk in more detail with folks to sort of strategize on a more individual level about strategies for different schools and different processes. So you actually covered this a little bit with the last question but we did have a question how can medical students get more involved with advocacy with people with disabilities. That's another really good question. I would encourage you to look in your local communities there's a few places, look for centers for independent living those are scattered all over the country. Those are places that's going to be hubs of disability advocacy and support patients in all aspects of life. And there are opportunities or programs that they're having where you can a number one, learn about what they do and how they support people in your community so that you can then share that information with your patients, but also there may be ways that you can more actively get involved in the work that they do. The second is to look for adaptive sports opportunities and places where there are large rehab hospitals often there's adaptive sports programs associated with those hospitals but sometimes they're more independent community, community opportunities. There's also Special Olympics that operates in a lot of different places that's a great additional place to get experience working with people with disabilities and often they need first aid volunteers and medical students are eligible to that to do that is a really cool way to apply some medical knowledge to work with people with disabilities learn from their experience and their families, and also pick up medical skills that you'll have a head medical oversight. And so you'll pick up some skills along the way to. I don't see any other questions in the chat box right now but I am going to ask you because I make everybody answer this. Can you tell us a little bit about why you decided to go into physiatry and what kind of led to you practicing in this specialty. Yeah, that's a great question. So I was really attracted to physiatry for exactly the opportunities that we've been talking about to develop a really informed perspective on advocating for people with disabilities within our healthcare system. Physiatrists, as a whole, practice really good accessible clinical care, because very like obvious to an inpatient physiatrist that you need. For example, on the spinal cord injury unit right you need to have an overhead electric bed lift. When we discharge our patients we need to know, are they going to be able to get into their homes and if they're not how are you going to set that up, and those are things that were really important and valuable to me and thinking about how our patients live their lives and I felt really at home with a set of colleagues who felt and thought about the same things as I did, particularly for things that are not strictly medical. So, you know, making sure that a person has ramps into their home, you're not going to get tested on that on your boards, but you ask your patient what they care about and how are they going to feel their best and do their best. It might involve being able to get into their home. Value those kinds of things as part of your care, you can apply that to your patient care in whatever specialty that you choose and you can choose to be a good clinician in those ways. But, but if you really want to feel at home among folks who think the same way and for whom those questions are also automatic and physiatry, it's kind of your place. So much for having me and thank you everybody for chiming in. Hope to hear from you guys feel free to email me anytime. Have a great day.

physiatrists

comprehensive care

physician bias

inclusive care

disabilities

healthcare disparities

accessible care

disability education