about internal medicine :: Article CreatorComplaints Mount That Doctors With Disabilities Face 'ableist' Field Of Medicine
TRENDING: As growing criticisms argue the medical field discriminates against physicians with disabilities by failing to provide them proper accommodations, some physicians ask: 'What about the patients?'
"Ableism is entrenched in the culture of medicine and represents bias against and devaluation of physicians with disabilities," wrote Dr. Michael Quon in a recent issue of JAMA, the American Medical Association's journal.
Quon, a doctor in the University of Ottawa's Department of Medicine, is a disability advocate who struggled to return to his profession after suffering a traumatic brain injury in 2015.
In his article he claimed that although current policy recommendations allow physicians greater flexibility for tending to their own health, such recommendations fail doctors with physical, psychological, or cognitive disabilities requiring more extensive accommodations.
"Ableism is a social prejudice that defines persons with disabilities by their disabilities and characterizes them as being inferior to those who do not have disabilities," Quon wrote.
Future recommendations, he wrote, should include the removal of "barriers to accessibility" and should "apply best practices of confidential and adequately funded accommodations."
Quon's article was one of several pieces in recent months addressing alleged ableism in medicine to appear in the American Medical Association's flagship journal or one of its related publications.
Collectively, the string of articles argue the medical field discriminates against physicians with disabilities by failing to provide them with proper accommodations such as more flexible work schedules, physical changes to buildings, and assistive technologies. As a result, the articles claim, these physicians feel devalued personally and professionally.
For example, a research letter published via JAMA Network Open highlighted how Stanford Medicine faculty, students, trainees, and staff with disabilities are less likely to feel connected to their institution's mission or feel valued by their institution.
Dr. Lisa Iezzoni, author of an invited commentary for JAMA Network Open regarding perceived and structural ableism in the medical field, wrote that addressing such concerns "could attract and maintain more health care professionals and trainees with disabilities" and subsequently benefit patients.
Yet, not all physicians are onboard with the idea that the medical field is inherently ableist.
Dr. Clayton Baker, an internal medicine physician and former clinical associate professor of medical humanities and bioethics at the University of Rochester, told The College Fix in an August telephone interview: "I'm not sure that [Quon's] fundamental premise is entirely true."
"In terms of something that could really be actionable, I found the language of his paper to be extremely vague," Baker said.
These pieces also have spurred some physicians to ask: "What about the patients?"
This was the question posed by Dr. Russ Gonnering, retired ophthalmic plastic and reconstructive surgeon and author of the Critical Thinking in Healthcare Substack, when asked about Quon's article in an August telephone interview with The College Fix.
"Where does the patient fit in?" he asked. "If these accommodations are needed even for a physician who has cognitive impairment, is the patient…[told] 'Your doctor may not be up to snuff on things, but we're going to make you see him anyway?'"
"I mean, it's something that's so bizarre to me…that I almost wonder why we're even talking about this," he said.
Dr. Steven Kritz, a retired physician who now serves as the chair of an institutional review board at a not-for-profit health care agency, similarly told The College Fix in a telephone interview he believes this emphasis on combating alleged ableism in medicine is "getting away from the fact that the whole idea of having people go into medicine is so that they have the skill set and the ability to take care of patients."
"I did rural care for twenty years," Kritz said. "It was more grueling than my first year as a resident, which is usually considered the ultimate hazing."
In rural care practice, he said, "we're in a situation where on a regular basis you were called upon to make decisions about whether people lived or died."
"There's a skill set," he said. "There's a certain physical capability."
Of the physicians interviewed by The Fix, none inherently were opposed to allowing physicians with disabilities to practice medicine.
Gonnering and Baker even highlighted examples of physicians with disabilities that managed to become assets to their field, such as Charles Krauthammer, a psychiatrist and Pulitzer Prize winning political commentator who became paralyzed following an accident while in medical school.
Yet, all agreed that sometimes a disability can limit the type of work a physician can do.
"I was an ophthalmic plastic surgeon," Gonnering said. "When I herniated a disc in my neck and I lost the fine motor control in my dominant hand, I knew it was time for me to stop doing surgery. … I didn't expect that the patient was going to put up with substandard results because of my disability."
Consequently, Gonnering said he went on to work for the remainder of his career in a non-surgical capacity.
However, both Gonnering and Baker noted some of the JAMA pieces lacked clarity regarding whether certain types of disabilities, such as the one Gonnering experienced, should ever disqualify a physician from certain types of work.
"[Quon] doesn't really address one of the fundamental questions regarding disabled physicians, which I think is totally necessary to address, which is 'Can they still do the specific job that they want to do?'" Baker said.
The College Fix attempted to contact Quon via email but did not receive a response.
According to Iezzoni's commentary for JAMA Network Open, the answer to this concern is the disabled physician still needs to be able to perform the essential functions of their position either unaided or with reasonable accommodations. Her commentary also stated that maintaining patient safety is an essential function of those working in health care.
However, in practice, it can be unclear what constitutes a reasonable accommodation and whether a health care professional's disability threatens a patient's safety.
In an August opinion piece for JAMA Internal Medicine, for example, Kelsey Biddle, a disabilities advocate with narcolepsy and student at Harvard Medical School, wrote of her own experience struggling to stay awake while operating a uterine manipulator as she assisted a resident in a surgery to remove a patient's tumor.
"I bite my inner cheeks, hoping a twinge of pain will keep me alert," wrote Biddle. "I taste blood, biting harder, but continue to yawn…I subconsciously tighten my grip on the handle to maintain tension as my attention fades."
"I strain my eyes, fixing my gaze on the uterus as its edges blur, pinks and browns swirling like a kaleidoscope. A young girl's face appears on the screen, her pigtail braids resembling fallopian tubes. Her lips move, and I hear the distant sound of my name…I jolt awake."
According to Biddle's account, she needed a break to either do leg exercises or possibly take a nap. She also wrote that although she had informed the resident before the procedure of her disability and potential need for a break, she did not request one due to concerns over interrupting the resident's workflow and that mid-surgery breaks went against the norms of her field.
In a followup email to The Fix Gonnering noted "the overall tone in [Biddle's] article is disturbing."
The College Fix communicated with Biddle via email in an attempt to set up an interview. Questions were included in one email regarding whether she believed her patient was in any danger and whether she felt the resident performing the surgery fully understood the possibility she could fall asleep during the procedure.
Biddle, however, ultimately declined to speak with The Fix.
In his followup email to The Fix, Gonnering reiterated his major problem with articles such as Quon's and Biddle's "is the complete absence of the point of view of the patient."
"Are they expected to 'make the necessary accommodations' so the physician's disability diversity can be celebrated?" he asked. "Is there informed consent for that?"
MORE: Doctors protest proposed DEI emphasis in Canadian medical school training
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The Heart Of The Question: Who Can Get Medicare-covered Weight Loss Medicine?
Millions of older Americans with obesity could potentially get Medicare's help with the hefty price of a weight-loss medication in order to reduce their high risk of heart problems.
But exactly what level of cardiovascular risk should make someone eligible for such coverage, how many people could become eligible, and what could it cost the nation?
A new study dives into these questions. It finds a wide range of answers that differ by millions of people and billions of dollars, depending on how private insurance plans that contract with Medicare are potentially allowed to proceed.
As many as 3.6 million people are most likely to qualify. This assumes plans only allow people with obesity who have already had a heart attack or stroke, or gotten diagnosed with coronary artery disease or angina, to get coverage for semaglutide injections, the study suggests.
That number doesn't include the 7 million who may already qualify because they have diabetes plus obesity.
The study was led by Alexander Chaitoff, M.D., M.P.H., a VA Ann Arbor Healthcare System and University of Michigan Medical School researcher, and published in the Annals of Internal Medicine.
But what about older people with obesity who don't have diabetes and haven't yet had a major cardiovascular diagnosis, but have elevated odds of a heart attack or stroke in the next 10 years?
If prescription drug coverage plans allow those with the highest cardiovascular risk scores to get full or partial coverage of the cost of semaglutide, another 5.1 million Americans could qualify the study finds. And if plans allow people with intermediate risk to qualify for coverage, another 6.5 million people could be eligible.
Medicare coverage of semaglutide -- but for whom?
Chaitoff and his former colleagues at Harvard University launched the study after the announcement this spring that Medicare would allow coverage of semaglutide for enrollees in drug plans if they had established cardiovascular disease. The drug is sold as Wegovy when used for weight loss, and Ozempic when used for diabetes.
Without a specific definition from Medicare of what constitutes "established cardiovascular disease," Chaitoff said, "it's unclear of exactly who will quality now, who may qualify in the future, and if certain high-risk people will be left out."
Medicare plans may be more likely to go with the short list of diagnoses that people had to have in order to qualify for the clinical trial that led to semaglutide's approval for cardiovascular disease and obesity.
But they could potentially take more of a preventive approach -- like they do with many medications that reduce the risk that someone will have a heart attack or a stroke.
Chaitoff, who provides primary care to veterans at VAAAHS, notes that Medicare Part D and Medicare Advantage plans could opt to set conditions to determine which high-risk patients could qualify for treatment with semaglutide. They could also tell them to share more of the cost.
He notes that veterans with obesity and at least one obesity-related condition can qualify for Wegovy coverage from the Veterans Health Administration if they participate in the MOVE weight management program over months or years.
But for everyone else over age 65, it's up to the plan that they've chosen during Medicare Open Enrollment to provide their prescription drug coverage.
"If those plans focus on coverage for people with the same conditions as in the clinical trial, 1 in 7 Medicare participants with obesity would now have access, which is an important expansion," said Chaitoff. "However, the other 6 of the 7 would not, and most of them also have an elevated cardiovascular risk based on their overall health status."
Risk scoring for future cardiovascular disease
The researchers used data from the National Health and Nutrition Examination Survey, conducted in samples of the United States public every year. This allowed them to calculate cardiovascular risk scores for every Medicare-enrolled person with a body mass index of 27 kg/m2 and above who didn't already have a history of heart attack, stroke, coronary artery disease or angina.
The scoring tool is called the ASCVD, and incorporates many factors to help guide clinicians who are trying to decide what preventive treatments a person might need. Those who score 20% or above are considered high risk for heart disease or stroke, while those who score 7.5% to just under 20% are considered intermediate risk.
Chaitoff notes that people who score above 20% should get immediate treatment to reduce their risk -- which typically includes drugs to reduce blood pressure, cholesterol, and even potentially pre-diabetic elevated blood sugar levels, as well as help with quitting tobacco, increasing physical activity, improving diet and losing weight as necessary.
In fact, he says, this is the same approach used in those who have survived a heart attack or stroke, or gotten a diagnosis of CAD or angina.
But those with scores between 7.5% and 20% also should get help reducing the risk factors that affect their score, which often includes medication.
"In practice, the way we treat both groups of people with elevated risk scores is not dissimilar -- we're making medical management decisions and lifestyle recommendations to prevent a future incident," Chaitoff explained. "Weight loss is listed in clinical guidelines as recommended for both groups, because of the general link between obesity and cardiovascular risk. But the only way Medicare will allow coverage of weight loss medication may have nothing to do with risk, only past diagnosis."
Coverage of medications that have been shown to lead to sustained weight loss -- as multiple medications including semaglutide have been -- would enable more people with obesity and elevated cardiovascular risk to achieve the goals set out in clinical guidelines, he added.
"Ultimately we need to ask ourselves, what level of evidence are we requiring for coverage of certain drugs, compared with the level of evidence that we require for coverage of other treatments," Chaitoff said. "With all that we know about obesity's impact on cardiovascular risk, it may be best to accept that a surrogate outcome of sustained reduction in weight is reasonable enough evidence for coverage. We do that for other conditions, but not obesity, and the questions are, why and is it appropriate."
Potential costs to Medicare
Semaglutide costs for Medicare plans will likely be the target of negotiations between the Centers for Medicare and Medicaid Services and the manufacturer of FDA-approved versions of the drug. But the price that is reached in those negotiations will only take effect the following year.
In the meantime, if only those with a history of heart attack or stroke are allowed to get it under the non-diabetes approval, and only 30% of them start the drug and stay on it for a year, the cost to Medicare could top $10 billion at current prices, the researchers estimate.
Women In Medicine: Our Journeys
The annual Women in Medicine Month webinar, sponsored by the Women Physicians Section (WPS), celebrates women physicians and students.
Register for our annual WPS Women in Medicine Month webinar on Sept. 26 at noon Central. Join us as Tami Benton, MD, presenter; Diana Ramos, MD, MPH, MBA, presenter; Megan Srinivas, MD, MPH, presenter; Gloria Wu, MD, moderator; and Deborah Fuller, MD, moderator, discuss ways to support women in medicine as they face challenges in aligning their career goals with personal responsibilities.
Tami Benton, MD
Dr. Benton is the Frederick H. Allen chair in child psychiatry at the Children's Hospital of Philadelphia (CHOP). She is the psychiatrist-in-chief and chair of the Department of Child and Adolescent Psychiatry at CHOP and professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania.
She directs the Child and Adolescent Mood Program and the Youth Suicide Prevention Center at CHOP. She is the president of the American Academy of Child and Adolescent Psychiatry (AACAP) and the past president of the American Association of Directors of Child and Adolescent Psychiatry (AADCAP).
Diana Ramos, MD, MPH, MBA
Dr. Ramos is California's second surgeon general and first Latina surgeon general. As California's doctor, she is the leading spokesperson on pressing public health issues within the state. Her mission is to advance the health and wellbeing of all Californians.
Over the past three decades, Dr. Ramos has provided reproductive care to Californians as an ob/gyn at Southern California Kaiser Permanente. Dr. Ramos' leadership spans from the local level in Los Angeles County where she previously served as the director for reproductive health, prior chair for the American College of Obstetricians and Gynecologists, California & Ecuador (IX) District.
Megan Srinivas, MD, MPH
Dr. Srinivas was elected to represent District 30 in the Iowa House of Representatives in 2022. She received her undergraduate and graduate degrees from Harvard University and her medical degree with a certificate in teaching from the University of Iowa's Carver College of Medicine.
She completed her internal medicine residency at Johns Hopkins School of Medicine and infectious disease fellowship at the University of North Carolina. She is an infectious disease physician, public health policy researcher, and serves as an ID expert for Iowa Primary Care Association. Dr. Srinivas also hosts the "Stories of Care" podcast.
Gloria Wu, MD
Dr. Wu, a graduate of Harvard University, Columbia University Vagelos College of Physicians and Surgeons, completed her ophthalmology residency at New York Presbyterian Hospital, and retina-vitreous fellowship at the Massachusetts Eye and Ear Infirmary, part of Harvard Medical School.
She is currently the president of the Santa Clara County Medical Association and the co-president of South Bay American Medical Women's Association. She serves on the AMWA Executive Board and serves on the governing council of AMA's Women Physicians Section. She is also a clinical instructor at the University of California San Francisco School of Medicine, Department of Ophthalmology.
Debbie Fuller, MD
Dr. Fuller is a highly respected and accomplished ob/gyn both locally and nationally. In addition to her private practice duties, she is a member of the residency teaching staff as an attending in the Department of Obstetrics and Gynecology at Baylor University Medical Center, Dallas.
She also serves as an associate professor in the Department of Obstetrics and Gynecology for the Texas A&M Medical School and is the president of the Dallas County Medical Society. Her primary focus areas in organized medicine have been the role of women physicians in medicine and state and national medical legislative issues.
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