Impact of USMLE Step-1 accommodation denial on US medical schools: A national survey

Abstract

Introduction In 2019, 4.6% of US-MD students self-identified as students with disabilities (SWD); many of these students will require accommodations on the USMLE Step-1 examination. Given the high-stakes nature of Step-1 for medical school advancement and residency match, SWD denied accommodations on Step-1 face considerable consequences. To date no study has investigated the rate of accommodation denial and its impact on medical school operations. Methods To investigate the rate of accommodation denial and evaluate whether Step-1 accommodation denial impacts medical school operations, a 10-question survey was sent to Student Affairs Deans and disability resource professionals at all fully-accredited US-MD granting programs. Two open-ended questions were analyzed using qualitative content analysis. Results Seventy-three of the 141 schools responded (52%). In the 2018–2019 academic year, 276 students from 73 schools applied for Step-1 accommodations. Of these, 144 (52%) were denied. Of those denied, 74/144 (51%) were delayed entry into the next phase of curriculum and 110/144 (76%) took the Step-1 exam unaccommodated. Of the 110 who took Step-1 without accommodations, 35/110 (32%) failed the exam, and 4/110 (3%) withdrew or were dismissed following exam failure. Schools reported varied investments of time and financial support for students denied accommodations, with most schools investing less than 20 hours (67%) and less than $1,000.00 (69%). Open-responses revealed details regarding the impact of denial on schools and students including frustration with process; financial and human resources allocation; delay in student progression; lack of resourcing and expertise; and emotional and financial burdens on students. Discussion Step-1 accommodation denial has non-trivial financial, operational, and career impacts on medical schools and students alike. The cause of accommodation denial in this population requires further exploration.

Assessment of Accommodation Requests Reported by a National Sample of US MD Students by Category of Disability

“…Given the risks associated with lack of disability accommodations when needed, schools should highlight the availability of accommodations and increase efforts to encourage accommodation requests, especially among students with cognitive disabilities. Future studies should investigate possible factors serving as drivers of nonrequests.…”

“…Access to accommodations is critical for medical students with disabilities and may explain differences in performance, program persistence, and graduation . Lack of accommodations has also been associated with greater risk of increased depressive symptoms and self-reported medical errors among training physicians .…”

Disability, program access, empathy and burnout in US medical students: A national study

“…57 Lack of access to needed reasonable accommodations has also been associated with lower scores in standardised exams and delayed student progression among medical students with disabilities. 58,59 While physicians with disabilities may be a critical part of a multifaceted approach to advancing health equity, there is a dearth of research that examines empathy and burnout measures for medical students with disabilities. Systematically assessing this data will allow for a more nuanced understanding of the experiences of students with disabilities and uncover the potential need for additional support.…”

“…Systematically assessing this data will allow for a more nuanced understanding of the experiences of students with disabilities and uncover the potential need for additional support. In addition, given prior evidence that program access is closely linked with the wellbeing and performance of disabled trainees, [56][57][58][59] and the emphasis on disability access across international recommendations, 1,26,53,54 research on the associations between program access, burnout, empathy and self-reported disabilities has the potential to identify possible targets of intervention to better support the well-being and performance of this diverse and valued population.…”

Disability inclusion in medical education: Towards a quality improvement approach

“…19 The 'State' of disability inclusion can be measured by systemic barriers to access, which lead to disparate outcomes for trainees with disabilities compared to their non-disabled peers. 20 These barriers are present in several domains, including: admissions, 3,21,22 instruction, 18 process, 16 access to accommodation in medical training and licensure exams, 23,24 lack of knowledge regarding reasonable and appropriate accommodation/ adjustments 3,16 and discriminatory practices for physician licensure. 24,25 In the context of an ableist and historically hostile environment.…”