In both New Zealand’s medical schools, and in medical schools in Australia, there are ongoing efforts to increase the representativeness of medical student cohorts, with the aim of ensuring that they better reflect the different communities they will serve, particularly in terms of ethnicity, rural background and socio-economic background.[[1,2,3]] The current health reforms in New Zealand place emphasis on health workforce development as a means of achieving equitable health outcomes.[[4]] The focus of this article is on students with a disability, and how to increase the representativeness of the medical workforce for people with a disability. We summarise the main recommendations of a new guidance document from Medical Deans Australia and New Zealand (MDANZ), which argues that the culture of medical schools is of central importance in ensuring that students with a disability are welcomed into medical schools, feel safe and are valued for their strengths and perspectives.[[5]] This principle applies equally to students who acquire a disability while they are at medical school.

Medical schools in New Zealand and Australia have a history of educating graduates who meet the accreditation standards of the Australian Medical Council and are, theoretically, capable of pursuing any branch of medicine.[[6]] Unlike many other university courses, medical education is outcomes based and closely linked to the expectation that the majority of graduates will practice as doctors. These factors, along with the regulatory context and the requirement for patient safety during medical school training, add layers of complexity to medical education in relation to how medical schools select, support and educate students.

People with disabilities have long faced challenges in studying medicine.[[7]] It is likely that people with a disability have historically been under-represented in the medical profession.[[7]] Contributing factors include the heterogenous nature of disabilities, and students’ fear of disclosing their disability because of stigma and concern that doing so might have negative consequences for future training and career opportunities.[[7,8,9,10,11]]

We recognise that there are differing views within the disability community about how people with a disability prefer to be acknowledged. We have chosen to refer to “students with a disability” as this language is reflective of the “person first” approach in the United Nations Convention on Rights of Persons with Disabilities, which both Australia and New Zealand have ratified. We have consulted widely and acknowledge our use of language may not be consistent with preferences among some disability stakeholders.

Recently, MDANZ reviewed its 2017 guidelines Inherent requirements for studying medicine in Australia and New Zealand.[[12]] The term “inherent requirement” refers to “the fundamental components of a course or unit that are essential to demonstrate the capabilities, knowledge and skills to achieve the core learning outcomes of the course or unit, while preserving the academic integrity of the university's learning, assessment and accreditation processes”.[[12]] The 2017 guidelines were intended to aid medical schools’ selection processes and enable greater access for students with a disability to study medicine, while maintaining safe clinical care.[[12]] This paper outlines the process and outcome of the review of the 2017 guidelines.

Process of the review

A working group was established by MDANZ in 2019 to lead the review process, which is presented in Figure 1. Members included representatives from 13 medical schools, regulators of primary medical programs and medical practitioners in Australia and New Zealand, and representatives of student and disability peak bodies. Evidence was gathered through a literature review and two separate and extensive consultation processes. The group explored the impacts of the 2017 Inherent requirements document and its equivalent in other jurisdictions, factors to consider when developing and assessing the ability to demonstrate achievement, including reasonable adjustments, and the statutory and regulatory landscape where these assessments take place. “Reasonable adjustments” refers to the provision of supports that are considered reasonable to enable students who have a disability to participate on the same basis as students without a disability.[[13]]

The final guidance document was fully endorsed by MDANZ and released in 2021.

View Figures 1–2.

Outcome of the review

The review resulted in the new MDANZ guidance document, Inclusive Medical Education: guidance for applicants and medical students with a disability.[[5]] It proposes a strengths-based approach to supporting students with a disability to study medicine and identifies seven key elements for medical schools to consider in facilitating an environment that supports potential or current students with a disability to study medicine, presented in Figure 2. This strengths-based approach places value on the perspectives and experiences that students with a disability bring to medical training and to the practice of medicine.

The new document presents a shift in thinking away from a medical model of disability, towards a social model of disability, which recognises that a person’s ability to complete a task is influenced by their interaction with their context (the environmental and personal factors unique to their situation).[[14]]

Medical schools operate in an area of some tension. There are times when regulatory requirements, the law, and the expectations of students, those who employ medical graduates or fund medical training may be in conflict. In addition, medical education is both theory and practice based. It requires active participation in diverse workplace environments to develop the skills necessary to meet regulatory standards and to become a competent doctor. In providing outcomes-based education and involving patients in learning and assessment activities, medical schools sit at the intersection of these factors.[[10,15,16]]

Given the individual nature of each person’s abilities and circumstances, a guidance document cannot resolve all the tensions. Rather, principles-based guidance was developed to support decision making by medical schools and potential or current students with a disability. To this end, students with a disability should be provided with early and ongoing information about their career options, and clear expectations about what can and cannot be assured by a medical school so that students can be empowered to make decisions about their own future. This process may include early consultation with the Medical Council of New Zealand to ensure the student and medical school have a shared understanding of any possible limitations or challenges to registration, internship or future employment. Matters of fitness to practice and competency are separate and may only in specific circumstances be related to a person’s disability. Assessing the capacity of a student with a disability to progress through a medical degree should not be conflated with their fitness to practice or competency, without first assessing whether adjustments required are reasonable.

The review also demonstrated how a narrow or broad interpretation of a single regulatory standard can determine whether a person is eligible to train as a doctor. For example, does “performing CPR” require a student to physically perform the task themselves or can they direct others to do so? In this sense, regulatory standards can be seen as a powerful enabler or barrier to inclusion, depending on how learning outcomes are phrased.

The working group, which included members with a disability, disability rights advocates and representatives from regulatory bodies, made the decision to steer away from providing scenarios and examples in the guidance document. The basis for this decision was that examples would necessarily need to be abbreviated and simplified for inclusion in the new guidance document, running the risk of taking the emphasis off the need for positive cultural settings within medical schools and the centrality of good processes (as illustrated in Figure 2), the risk of essentialising different aspects of disability and the risk of not properly conveying the complex, interdependent variables that go into decision making. Reasonable adjustments are made at different points in a medical degree in the context of diverse assessments and learning and working environments where students are assessed. In addition are the highly individualised natures of individuals’ disabilities and the varied facilities available at universities and health services. Instead, the working group recommended the formation of a Special Interest Group for Australian and New Zealand medical school staff to share experiences and learnings to better support applicants and students with a disability. Establishing this network provides an ongoing community of practice for discussion and debate acknowledging that, because of the individualised nature of disability, it is not possible or desirable to construct strict “rules” in relation to students with a disability.

Discussion

The new guidance document was underpinned by the following principles:

• Adopt an inclusive, strengths-based approach.

• Problematise the learning environment rather than the disability.

• Adopt a social model for disability that considers each person’s abilities on an individualised, context-specific basis.

• Encourage early and open dialogue through inclusive practices and culture.

The guidance acknowledges that: no two students are the same, even if their conditions appear similar; context matters; people with less-visible disabilities often face different challenges compared to those with more visible disabilities;[[17]] and a person’s abilities also change depending on their learning or working environment, or the activities expected of them.[[17]]

Facilitating an inclusive culture in medical schools, one that values and proactively enables the participation of diverse students, was identified as fundamental to implementing a strengths-based approach. Supporting students relies on early disclosure by students with a disability. To do this, students need to feel confident that disclosing their disability will not have an adverse effect on their application or progression. An inclusive culture not only enables this, it also makes students with disabilities feel seen and valued for their abilities.

The approach set out in Figure 2 demonstrates how achieving an inclusive culture requires an active, deliberate and multifaceted approach across all stages of a medical program. This approach seeks to work with students with a disability and empower them to feel confident seeking adjustments where required. It also sets out the opportunities for medical schools to be proactive in developing learning environments that are inclusive for all students, with or without disabilities. This includes empowering and motivating staff to actively seek opportunities to support and enable students with a disability to study medicine if they desire, and to meet the relevant selection criteria. In this sense the onus on facilitating an inclusive culture and environment is shared between both students and the medical school. The process of the review provided insights into the challenges faced by students with a disability and medical schools in supporting them, and the necessity of ongoing reflections on the progression of social norms in the area of disability. The review also required an examination of the assumptions, biases and preconceptions of those engaged in the review process. For example, should a student with limited mobility in their arms be automatically considered ineligible for studying medicine if they could not undertake a physical examination without assistance? The working group consistently challenged assumptions that, by default, people with a disability should be excluded from medical education because they cannot undertake a task in an identical manner to a person without a disability. While the guidance document acknowledges that, even with reasonable adjustments, there may be cases where a student will not be able to meet the requirements of the medical program, this should not be the default or primary assumption. Rather, the emphasis is on early discussion between the medical school and applicant or student about what alternative means are available and reasonable to enable the student to undertake the programme’s components and demonstrate their achievements in all key areas.

A broadly representative working group, extensive consultation and inclusion of people with a disability were critical to creating a new, widely accepted document. The diverse mix in the working group of senior leaders from medical schools and regulatory bodies, university support staff, students and people with lived experience of completing medical school with a disability made challenges to traditional thinking more likely and welcome. The inclusion in the working group of people with the experience of completing medical school with a disability provided insights about what matters to people with a disability and the challenges they face in medical school and in employment. Targeted and extensive consultation provided insights from stakeholders who play a role in the accreditation, design, delivery and funding of medical education, as well as from those responsible for registration and employment. Consultation also highlighted challenges that cannot be solved by guidance alone, but can be mitigated through open dialogue between medical schools and applicants and students.

Social norms will continue to evolve, requiring careful and frequent re-examination of both new technologies that will enable greater participation and biases related to who can and should be our doctors. How these biases are manifested in our policies, processes and regulatory standards related to the education and registration of future doctors will change over time, and constant vigilance will be required.

Navigating through the practicalities of providing support that meets students’ environmental and personal needs—and the legal, regulatory and policy framework in place—poses challenges. While centralised disability services provide university-wide support, identifying and tailoring adjustments that meet the specific, and often unique, demands of the medical programme is resource- and time-intensive for medical school staff. This process may require extensive and ongoing consultation with a range of stakeholders, including supervisors and coordinators at different clinical placement or workplace locations, and potentially engagement with regulatory bodies as well as with the student themselves. Additionally, medical schools do not determine a student’s eligibility for registration as a medical practitioner after graduation—this decision is made by the Medical Council of New Zealand based on regulatory requirements. This division of responsibility adds a layer of complexity when assessing the reasonableness of adjustments in both learning and workplace environments.

The COVID-19 pandemic has only exacerbated resource constraints across the university sector and in some instances has significantly reduced capacity in the hospital sector to support the essential education and training of medical students. These pressures add further complexity to ensuring the preparedness of graduates for practice, and the breadth of potential adjustments required to achieve this.

Areas for future work could include the sharing of good practice examples of reasonable adjustments that enable a range of people with a disability to study medicine, and also sharing experiences of the limitations of reasonable adjustments.

Conclusion

The review explored evolving medical, health and social attitudes in relation to people with disabilities, resulting in a strengths-based guidance document that is reflective, we hope, of our aspirations for inclusiveness. An inclusive approach to medical education is essential to achieving equitable representation of doctors with a disability in the medical workforce. This work is never complete—as social norms and technologies evolve, re-examination of our expectations and approaches will continue to be necessary.