NCD Response Letter to Liaison Committee on Medical Education Regarding Integration of Disability Curriculum Requirement

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May 30, 2019

Dr. Stephen Ray Mitchell
Chair, Liaison Committee for Medical Education
Med-Dent Building, NW 106
Box 571416
Washington, DC 20057

Dr. Veronica M. Catanese
LCME Co-Secretary and Senior Director
Accreditation Services
Liaison Committee on Medical Education
Association of American Medical Colleges
655 K Street, NW, Suite 100
Washington, DC 20001

Dr. Barbara Barzansky
LCME Co-Secretary and Director
Undergraduate Medical Education
Liaison Committee on Medical Education
American Medical Association
330 North Wabash Avenue
Chicago, IL 60611

Dear Drs. Mitchell, Catanese, and Barzansky,

This letter will serve as a response to the letter sent by Dr. Mitchell on behalf of the Liaison Committee on Medical Education (LCME) dated February 19, 2019. That letter informed NCD that, in response to NCD’s recommendation that the LCME formally integrate a requirement for curriculum on developmental disabilities[1] into Element 7.2 of the Functions and Structure of a Medical School, Standards for Accreditation of Medical Education Programs Leading to the MD Degree, the LCME’s view was that the LCME standards and associated elements are relatively broad and that LCME standards and elements do not reach the level of specificity required by NCD’s recommendation. Accordingly, NCD has again reviewed the LCME standards and associated elements and notes that those standards and elements do indeed entail an equivalent level of specificity to justify not only inclusion of specific developmental disability curricula, but also more general disability curricula where appropriate. Thus, NCD again recommends that the LCME formally integrate a requirement for curriculum on developmental disabilities into its Element 7.2, and also asks that the LCME formally integrate a requirement for curriculum on disability into its Element 7.6 as outlined in the paragraphs below. Element 7.6 already provides specificity regarding both gender and cultural biases, as well as the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments; and Element 7.2 already provides specificity concerning the potential health-related impact on patients of behavioral and socioeconomic factors.

In the same way that the LCME standards and related elements dictate that students should “learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the health care delivery process,"[2] students should also be trained to “recognize and appropriately address disability biases in themselves, in others, and in the health care delivery process.” Indeed, studies of health disparities among people with disabilities has shown that disability bias among doctors exists and can be rectified by better training.[3] Additionally, as the LCME Elements currently dictate that medical curricula include instruction regarding “the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments,”[4] they should also dictate that medical curricula include instruction regarding “the manner in which people with intellectual and developmental disabilities perceive health and illness and respond to various symptoms, diseases, and treatments” (a revision particularly relevant for patients who might utilize supports to  describe symptoms or adhere to management plans because of their disability, and might require an adapted approach in order to integrate the patient’s experience). Similarly, as the Elements currently state that medical curricula must include “instruction concerning the basic principles of culturally competent healthcare,”[5] they should also specifically include instruction regarding “basic principles of disability competent healthcare.” Finally, with respect to Element 7.2, just as the LCME expressed with specificity that students should be prepared to “recognize the potential health-related impact on patients of behavioral and socioeconomic factors,” the LCME should also express with specificity that students should be prepared to “recognize the potential health-related impact on patients of developmental disability factors.” If it is the LCME’s understanding that Element 7.2 is meant to be interpreted broadly, it is vital and certainly much clearer that an iteration be made that more specifically expresses the LCME’s intent that students should be prepared to recognize the potential health-related impact on patients with developmental disabilities.    

It is important to note that while there is ample research available to support the needs for such additional instruction,[6] the inclusion of such training is also a matter of LCME compliance with respect to its Americans with Disabilities Act[7] and Rehabilitation Act[8] obligations. Some schools are already moving forward and are making strides in including disability competency in their respective curricula, but your imprimatur will make it incumbent upon all schools instead of a notable, inclusive few. Further, while some might argue that developmental disability competency or disability competency in general is already part of the LCME Elements because Element 7.6 states that medical curricula must include instruction regarding “the importance of meeting the health care needs of medically underserved populations,” that argument is problematic because the disability population is not currently classified as medically underserved under law per the Public Health Service Act.[9] If it was, regardless of legal classification, the LCME’s understanding that Element 7.6 includes the disability population in the “medically underserved population” reference, than it is more clear, and certainly prudent, that here too the LCME states as much through a revision of its 7.6 Element.

Thank you for your time and consideration of this vital issue. Please contact Amged M. Soliman, NCD Attorney Advisor, at asoliman@ncd.gov or 202-272-2116 should you have any questions.

Sincerely,

Neil Romano
Chairman




[1] In using the term “developmental disabilities,” NCD is referring to intellectual and developmental disabilities.

[2] LCME. “Functions and Structure of a Medical School, Standards for Accreditation of Medical Education Programs Leading to the MD Degree.” Element 7.6.

[3] “Care of Patients with Disabilities: An Important and Often Ignored Aspect of Family Medicine Teaching.”

Jain S, Fam Med. Jan. 2006; 38(1).13-5. See also “Health Professional Student Attitudes Towards People with Disability.” Tervo RC, Palmer G, Redinius P, Clin Rehabil. Dec. 2004; 18(8):908-15. See also “Cross-disability Experiences of Barriers to Health-care Access.” Drainoni M, Lee-Hood E, Tobias C, Bachman S, Andrew J, Maisels L, Journal of Disability Policy Studies. 2006;17:101–115. See also National Council on Disability. 2009. “The Current State of Health Care for People with Disabilities.”48-49.

[4] LCME. “Functions and Structure of a Medical School, Standards for Accreditation of Medical Education Programs Leading to the MD Degree.” Element 7.6

[5] Ibid.

[6] See footnote no. 3 herein.

[7] 42 USC § 12101 et seq.

[8] 29 USC § 794 et seq.

[9] 42 USC § 201 et seq.