Disability Inclusion in Undergraduate Medical Education

In April 2024, my colleagues and I convened a diverse coalition of medical educators, students, and researchers, and representatives from medical associations and accrediting bodies for the Access in Medicine (AIM) Summit in Chicago, Illinois.1 Supported by the American Medical Association (AMA), the Accreditation Council for Graduate Medical Education, the DocsWith Disabilities Initiative (DWDI), and the Shirley Ryan Ability Lab, the 60 delegates—invited for their expertise in and lived experience with disability inclusion in medical education—came together to identify the drivers of inequity for medical students with disabilities and propose actionable solutions and directions for future research.1 Through storytelling, focused discussion, flattened hierarchy, and accessible design, the event fostered community, surfaced collective insights, and generated actionable strategies.1 From this day of meaningful collaboration, our vision for this supplement was born. Our goals for this supplement are to fill gaps in the existing literature, particularly those related to intersectional identities, and elevate disability-informed scholarship and real-world practices, including calls for policy reform and case studies that demonstrate successful implementation and lessons learned. To achieve these goals, our editorial review committee—a diverse group of 35 learners and leaders from around the globe—articulated and then applied a set of foundational principles to guide their evaluation of the more than 40 submissions. Every manuscript was required to include learners as co-authors and reflect the contributions of disabled individuals, aligning with both the tenets of disability justice2 and emerging best practices for inclusive research.3,4 The 20 papers published in this supplement meet these goals and amplify the work of numerous research groups while centering the voices of learners and leaders through commentaries and first-person perspectives. Together, we—the editorial committee, authors, and Academic Medicine editorial staff—have produced a supplement that is rigorous, reflective, and deeply rooted in lived experience. As previewed here, the contents are organized into 6 themes: (1) Landscape of Disability Inclusion in Medical Education, (2) Learning Environment Enhancements, (3) Disability at the Intersections, (4) Barriers to Entry and Transition, (5) Frontiers in Disability Research, and (6) Case Studies in Disability Inclusion. Landscape of Disability Inclusion in Medical Education The first group of papers lays the groundwork for the supplement, beginning with the proceedings from the AIM Summit. As documented by Salinger and colleagues,1 the proceedings offer more than a summary; they provide a roadmap for change grounded in collective wisdom, contextual understanding, and an unwavering commitment to disability equity. Filling a considerable void in the literature, Maggio, Brown, and their team present a scoping review of the disability-in-medicine literature that should prompt us all to reconsider how we approach disability research.5 Their synthesis highlights current trends in scholarship and identifies critical gaps, including transitions into and out of medical school, the needs of students with less-apparent disabilities, and how disability intersects with other aspects of a learner’s identity.5 The authors also point out that much of the literature continues to rely on a deficit model, which may reinforce negative perceptions of disabled students and constrain how disability is understood within medical education.5 Cleveland Manchanda and colleagues offer a systems-level view from the vantage point of professional associations and accrediting bodies, challenging institutional leaders to wield their influence to advance inclusion.6 The authors present a compelling case for national organizations to play a catalytic role in changing the narrative, influencing policy, and reimagining the structures that support disabled learners and physicians.6 The section also includes the voices of disabled learners. In their piece, The Critical Nature of Belonging in Academic Medicine for Medical Students with Disabilities, Dhanani and colleagues offer a powerful commentary on the concept of belonging as they reflect on the critical role of peer-led efforts in building supportive communities and advancing equity for learners with disabilities.7 The commentary identifies 4 ways institutions can support inclusion; it also explores the importance of creating safe spaces that foster authenticity and demonstrates how this acceptance is linked to improved learner outcomes.7 They also describe the influential role student-led disability organizations play in developing community, offering mentorship, creating leadership opportunities, sharing resources, and advancing anti-ableism.7 Learning Environment Enhancements The papers in this section explore how structures, policies, and people shape the daily experiences of medical students with disabilities. Theall and colleagues propose expanding Gruppen’s conceptual model of the learning environment to include societal factors—which contribute to the complex psychosocial dynamics that influence medical education.8 The paper emphasizes the critical importance of understanding the learning environment as a dynamic, participatory space that actively shapes the development of learners’ knowledge, skills, and professional identities.8 The expanded framework enables educators to more thoroughly evaluate the quality of the learning environment and gain a more comprehensive understanding of how both individual and structural elements shape student experiences.8 Dhanani and colleagues, in a paper that should be essential reading for every U.S. medical educator, offer critical insights into the current use of clinical accommodations.9 Their first-of-its-kind study presents a consensus-based list of approved clinical accommodations drawn from 12 U.S. medical schools.9 By standardizing the language used in accommodations, the authors aim to promote accessibility and advance equity across medical education.9 They note the potential to improve communication and implementation practices by offering a shared vocabulary for describing clinical accommodations.9 Also in this section is a beautifully articulated perspective by Triano, who applies Bronfenbrenner’s Ecological Systems Theory to examine the central role of disability resource professionals (DRPs) in medical education.10 Triano’s analysis, supported by new data from national learning environment surveys,11 positions DRPs as essential influencers across the medical education ecosystem.10 The paper advocates for formal credentialing, tailored professional development, and increased inclusion of DRPs in medical education research.10 Triano’s argument for the centrality of the DRP role is echoed throughout this supplement, with many authors highlighting the critical need for DRPs with expertise in medical education. Disability at the Intersections Filling one of the most conspicuous gaps in the literature, the papers in this section interrogate how disability collides with other marginalized identities to intensify inequities in medical education. The authors do more than control for sociodemographic variables; several papers are sufficiently powered to conduct accurate intersectional analyses, offering a sharper picture of how multiple forms of oppression compound negative outcomes. Eidtson and colleagues’ multi-institutional Pathways II study,12 which builds on Pathways I,13 examines how intersecting identities shape academic disruption. Their findings are stark: medical students with disabilities who are also underrepresented in medicine (URiM) are at a disproportionately higher risk than their peers for leaves of absence and prolonged time to graduation.12 The authors call for future studies that are large enough to capture the full complexity of intersecting identities and urge schools to adopt flexible curricular pathways, strengthen disability services, and recruit disability resource professionals who are trained in both medical education and racial equity.12 Structural inequities beyond the classroom are the focus of Nguyen and colleagues’ multisite investigation into food insecurity.14 More than 1 in 4 medical students report inadequate access to nutritious food, but the prevalence soars above 60% for those who are simultaneously URiM, low-income, and disabled.14 After adjusting for age, gender identity, and year in training, students at this triple intersection face a 3.5-fold higher relative risk of food insecurity than their non-URiM, nondisabled, higher-income peers.14 The study links unmet basic needs to threats to academic progress, mental health, and professional identity formation, and recommends both institutional interventions (e.g., emergency meal programs, revisiting cost-of-attendance formulas) and broader advocacy aimed at the social determinants of health.14 A second paper led by Nguyen tackles the Timing of Disability Diagnosis and Accommodations During Medical School by First-Generation Status, Race, Ethnicity, and Gender,15 where researchers note that nearly half of all diagnoses occur after matriculation—a pattern most pronounced among first-generation and Black students—and delayed diagnosis is associated with a 50% reduction in receipt of preclinical accommodations.15 The authors recommend solutions that underscore how late recognition of nonapparent disabilities can amplify existing inequities across exams, rotations, and specialty choices.15 While delayed diagnosis highlights barriers to claiming disability, Pereira-Lima and colleagues draw attention to another challenge: disability status uncertainty.16 Students who respond “I don’t know” to demographic questions about disability report significantly higher burnout than both disabled and nondisabled peers, with the highest uncertainty rates among Asian, Black, Hispanic/Latino, multiracial, and male learners.16 The authors posit that ambiguity itself constitutes a stressor, compounded by limited access to resources and accommodations, and the stigma associated with seeking support.16 They call for curricula and services that normalize the discussion of disability, provide confidential screening, and mitigate the psychological toll of uncertainty.16 In an incisive commentary, Nguyen applies the Disability Justice framework17—developed by disabled queer and transgender activists of color—to critique surface-level inclusion efforts. Nguyen argues that without attention to power, privilege, and the historical exclusion of multiply marginalized communities, well-meaning reforms risk perpetuating the very inequities they seek to address.17 The commentary offers a roadmap for intersectional, justice-based change that centers lived experience, redistributes decision-making authority, and measures success by material improvements in learners’ lives.17 Taken together, these contributions uncover the compounded effects of race, gender, socioeconomic, first-generation, and disability status on everything from basic needs to time-to-graduation. They challenge medical schools to move beyond one-dimensional analyses toward policies and practices that address intersecting systems of oppression—an imperative if our profession is to train and retain a physician workforce that truly reflects and serves our diverse society.17 Barriers to Entry and Transition Access—both literal and symbolic—emerged as a dominant theme at the AIM Summit.1 This section examines the gatekeeping mechanisms that determine not only who enters medical school but also how smoothly learners progress through training and transition into residency. Ikedionwu and colleagues highlight one of the first and most visible measures of culture available to disabled medical students: inconsistent public messaging about disability inclusion.18 Their analysis of U.S. MD-granting medical school websites reveals that the average “disability-inclusion” score remains a middling 5.94 out of 10, with significant regional variation.18 Encouragingly, 93% of medical schools now publish technical standards on their websites—up from 86% in 201619—yet fewer than 40% explicitly include disability in their diversity statements.18 This omission signals a troubling lack of integration between disability and broader diversity, equity, and inclusion initiatives. The authors argue that, in the absence of national guidelines, schools interpret best practices inconsistently, leaving prospective learners to navigate a fragmented and often opaque landscape.18 If unclear messaging is the first hurdle, restrictive technical standards remain among the most persistent and widely cited barriers historically,20,21 and throughout this supplement. In a first-of-its-kind national evaluation, Singer and colleagues analyzed technical standards across all MD and DO programs,22 4 years after the AMA called for the adoption of functional in place of organic technical standards.23 Their findings are both encouraging and disheartening. While some schools have embraced inclusive language in recent revisions, many continue to rely on restrictive or vague criteria that may dissuade qualified applicants with disabilities. Alarmingly, the authors are forced to reiterate recommendations made over a decade ago, underscoring the inertia in this critical area of inclusion.22 In contrast to this amorphous approach to technical standards, a promising model has emerged from Canada.24 In what is perhaps the most celebrated national action on disability inclusion to date, Canadian leaders, faculty, and learners collaboratively developed Core Competencies for Students Entering Medical School: Reaching Pan-Canadian Consensus for Inclusive and Accessible Medical Education.24 This landmark report outlines a uniform, disability-informed framework endorsed unanimously by the Association of Faculties of Medicine of Canada.24 Guided by principles of transparency, accessibility, and a deep respect for disability as a form of diversity, the working group undertook a 5-phase process to develop competencies designed to support learners from medical school admission through postgraduate training.24 The report urges medical schools to adopt these competencies, expand accommodations support, and integrate disability inclusion as a core element of their social accountability mandate.24 Of course, policy documents and public messaging only tell part of the story. The transition from undergraduate to graduate medical education (UME to GME) remains a high-stakes inflection point where hidden barriers often re-emerge. In a timely and practical commentary, Sheets and colleagues distill lessons for this vulnerable period from decades of experience as learners with disabilities and leaders in GME.25 Drawing on both professional and personal insights, the authors identify 4 key areas where focused interventions are needed: (1) disability disclosure, (2) specialty selection, (3) program selection, and (4) requesting and utilizing accommodations.25 The authors argue that when institutions recognize disability as an asset to diversity, rather than a challenge to be managed, they can build a physician training system that is more equitable, effective, and responsive to the needs of all learners.25 Taken together, these contributions map the structural continuum of access: from the first website click to the fine print of technical standards to the complexities of the residency match. They reveal how seemingly minor inconsistencies in information, language, and process can aggregate into systemic exclusion. Yet they also point to clear, actionable solutions: transparent communications, functional and inclusive technical standards, national frameworks for accountability, and learner-centered transition protocols. Bridging these gaps is foundational to building a physician workforce that is diverse, inclusive, and prepared to serve the full spectrum of society. Frontiers in Disability Research The single, research paradigm-shifting paper in this section invites readers to scrutinize the very epistemic foundations on which inclusion scholarship rests. Jain and Stergiopoulos introduce the concept of double knowing—the deliberate pairing of research from different epistemic and ontological approaches to mutually enrich our understanding—and argue that methodological choices are never politically neutral; they shape what a study can know and, by extension, what it can change.26 Too often, they say, researchers committed to equity advance one paradigm at the expense of another, but Jain and Stergiopoulos resist this either–or framing.26 Drawing on their experience analyzing data from a national survey of medical students with disabilities, they conducted 2 parallel reflexive thematic analyses: one grounded in a critical realist–contextualist stance, and the other in a relativist–constructionist stance.26 The exercise demonstrates how each orientation illuminates different textures of marginalization and yields distinct yet complementary implications for policy and practice.26 This paper serves as a methodological provocation: advancing disability equity is not about choosing the “right” lens once and for all, but about cultivating epistemic flexibility—the capacity to see and act upon injustice from more than one vantage Case Studies in Disability Inclusion case medical school, and how disability access can be in clinical education. by of and institutional leaders, these the and real-world in Together, they offer a for sharing and a culture of and In both the and educators, describe how they to the learning environment accessible for and of students, highlighting not only what was but it the by the with Disabilities remain significantly underrepresented in often to institutional to support In the and colleagues the experience of a medical student at School of This case study a student with in one and in the other who medical education with a of tailored a and as services, and in and clinical The authors provide a comprehensive review of accommodations used throughout both and clinical training, underscoring the of The successful and residency of the learner demonstrates what is when accommodations are and the essential role of accessible learning in cultivating a diverse physician In the and demonstrate how accommodations can support in Their case demonstrates that when communication and are can not only but also meaningful contributions to education and clinical the made for the as team communication all of the both learning and As the authors creating access in is not a it is an in a more inclusive and clinical The case by and focus to the where the learner an and This case how the absence of in for barriers for both disability and other marginalized a residency experience, the learner unclear and stigma systemic gaps between institutions and the that disability is with medical experience the need for policies that for the compounded by those at the intersection of multiple forms of these the through medical education and training is not only more but also and may be a for a of institutional policies, and inconsistent The that should progress that they and navigate all while the of and structures that the full complexity of identity, disabled learners are to navigate a system that was not designed with in From medical school to residency to the case studies demonstrate the barriers that disabled learners the potential of They also reinforce a central of this institutional leaders and educators are not in their efforts to support their learners with disabilities. Through collaboration, transparency, and a to from one another, we can move the and that disability inclusion is not the but the in medical education. This is more than a of academic is a of collective and a shared commitment to equity. that disability inclusion is not a or a is central to the of academic is essential to the training of equitable, and As with these contributions to the literature, I to not only reflect but also this serve as both a and a a that reflects how we have and a map that us toward this a but meaningful where academic medicine to that access is a shared may we continue to to and to the us

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