NCD LCME 2nd Response Letter

Dr. David R. Lambert
LCME Chair

Dr. Tony Ganzel
LCME Chair-Elect

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
Director, Undergraduate Medical Education
Liaison Committee on Medical Education
American Medical Association
330 North Wabash Avenue
Chicago, IL 60611

Dear Drs. Lambert, Ganzel, Catanese, and Barzansky,

This letter will serve as a response to the letter sent by Drs. Catanese and Barzansky on behalf of the Liaison Committee on Medical Education (LCME) dated October 28, 2019. That letter informed NCD that, in response to NCD’s recommendation that the LCME formally integrate a requirement for curriculum on developmental disabilities into its Standards of Accreditation Element 7.2 and also formally integrate a requirement for curriculum on disability into its Element 7.6, the LCME elected to instead modestly revise Elements 3.4 and 7.6.

Per your letter, Element 3.4 will now state that a medical school must have a policy “in place to ensure that it does not discriminate on the basis of…disability…or any basis protected by federal law” and that the LCME elected to revise Element 7.6 to state, where relevant, that medical curriculum include content regarding “the recognition of the impact of disparities in health care on all populations and potential methods to address health care disparities”1 instead of the language previously used in Element 7.6 which stated where relevant that medical curriculum includes instruction regarding “the recognition and development of solutions for health care disparities.”

With the revision to its accreditation standard at Element 3.4, to explicitly add “disability,” Element 3.4 will inform medical schools that do not now already have “disability” included in their nondiscrimination statements to include it and thereby have a policy statement that more fully complies with their federal nondiscrimination mandates.   

The revision to LCME’s accreditation standard at Elements 7.2 and 7.6, in our view, makes no meaningful change to address the concerns raised by the NCD. While NCD understands that the LCME attempts to construct standards using general language in order to avoid language that might be interpreted as exclusionary, as it relates to the issue of disability specific cultural competency training, we believe strongly that the facts argue for inclusion of specific language. If specific language is not included in these Elements to require medical schools to incorporate disability specific cultural competency training, it is more than likely that schools will continue to not incorporate such training. To wit, Element 7.6 in particular was introduced by LCME in 2000 and in the past nearly 20 years that specific training remains absent from the overwhelming majority of medical schools.2 That fact was underscored in 2010 by the inclusion of Section 5307 of the Patient Protection and Affordable Care Act, a specific requirement for the development, evaluation and dissemination of  model disability cultural competency curricula for inclusion of such training in health professions schools and continuing education programs.

As we think the members of the LCME will agree, it is well known that persons with disabilities experience disparities in their healthcare, including in screening and prevention services, treatment of major health conditions, and reproductive health care, none of which are inevitable.3 Provider–level factors contributing to those health disparities include inadequate knowledge about disabling conditions and physicians holding erroneous assumptions about the values and expectations of individuals with disabilities, assumptions that mirror widespread, stigmatized societal views about disability. That lack of understanding contributes to less effective medical care for persons with disabilities. That lack of understanding needs to be addressed by training.

The LCME stands as the sole source of authority that can address this problem without further legislative mandate. It is vital that less vague language be used in this respect.

Curricula development in this space is already available for the LCME to use as a guide, curricula that many, though still a minority of, medical schools have begun adopting.

NCD hereby requests that the LCME reconsider and vote on these recommendations at its upcoming February 2020 meeting.  We would like to schedule a time for our respective staffs to meet to discuss further. Please advise as to your staff availability for early January 2020.

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 regarding your staff’s availability to meet.

Sincerely,

Neil Romano
Chairman

1 With the LCME listing “disability status” as one of the identifiers of “health care disparities” in the Glossary of Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree.

2 See Laurie J. Woodard et al., An Innovative Clerkship Module Focused on Patients with Disabilities, 87 Acad. Med. 537, 537 (2012)(citing to a Special Olympics survey finding that only 25% of medical schools have curricula covering caring for people with intellectual/developmental disabilities); cf. Letter from the NCD to the President of the U.S., Report on The Current State of Health Care for People with Disabilities (Sept. 30, 2009)(on file with the NCD)(“The absence of professional training on disability competency issues for health care practitioners is one of the most significant barriers preventing people with disabilities from receiving appropriate and effective health care.”); Gloria L. Krahn et al., Persons with Disabilities as an Unrecognized Health Disparity Population, 105 AM. J. PUB. HEALTH S198, S204 (2015)(“[D]isability competency is not currently a core curriculum requirement for medical school accreditation or for receipt of federal funding.”).

3 See Horner-Johnson W, Dobbertin K, Andresen EM, Iezzoni LI. Breast and cervical cancer screening disparities associated with disability severity. Wom Health Issues. 2014;24(1):e147ee153;  Iezzoni LI, O’Day B. More than Ramps: A Guide to Improving Health Care Quality and Access for People with Disabilities. USA: Oxford University Press; 2006; Iezzoni LI, Mitra M. Transcending the counter-normative: sexual and reproductive health and persons with disability. Disability Health J. 2017;10(3):369e370; Mitra M, Smith LD, Smeltzer SC, Long-Bellil LM, Sammet Moring N, Iezzoni LI. Barriers to providing maternity care to women with physical disabilities: perspectives from health care practitioners. Disability Heal J. 2017;10(3):445e450.