Medical school designees are charged with determining appropriate and reasonable accommodation plans for qualified applicants with disabilities (1). There are many misconceptions about providing accommodations for medical students; one of the most concerning is that incorporating accommodations into licensure exam environments decreases exam efficacy and presents concerns about ensuring that performance standards are met (6). The principle of inclusive education dictates that schools accommodate all learners in the classroom (4). An inclusive learning environment allows students to celebrate each other's strengths and support each other as they improve weaknesses (4) (12). The inclusive design incorporates the thoughts and principles of universal design for learning (UDL), which places high value on diverse student learning and inclusion of learning differences (12, 13). However, incorporating inclusive learning, students should still be referred so that their accommodation needs are met (12, 13). In a 2014 study, medical students with ADHD receiving accommodations reported significantly more prominent symptoms than those not receiving accommodations, indicating that students with the most severe cases of ADHD are receiving support; few investigations have looked at the efficacy of specific academic accommodations in this population (11). The 2014 study also confirms other reported findings (Searcy et al., 2005; Sharp and Earle, 2000), which suggest that test accommodations, including extra time, allow students with specific learning difficulties and ADHD to perform at the same level as their nondisabled peers [ref the 2014 study].
Testing accommodations are classified as alterations such as extended time, extra breaks, private room, and ability to bring snacks and medications are among some modifications to standard test administration to allow test takers with documented disabilities to show their proficiencies rather than the extent of their disabilities. Students whose MCAT scores were obtained with extra test administration time demonstrated no significant difference between these students matriculating into medical school admission than students with standard administration time (16) (7). However, students who took the MCAT with accommodations had lower passing the United States Medical Licensing Exam (USMLE) (16). Students who don't pass USMLE on the first try take longer to complete USMLE Step examinations, often resulting in delayed graduation (16) (12). For students with cognitive/learning disabilities who are unable to receive accommodations on the USMLE Step 1 exam, their scores are 12 points lower than the average population.
In contrast, those who receive accommodations are 6 points lower than the average population (14). This information further proves that barriers remain for competent students when not given their proper accommodations (14, 16, 12). Therefore, there is a need to investigate the medical education learning environment to ensure robust support systems for these students (16).
In Searcy et al. (2015), mean MCAT scores and acceptance rates were not significantly, 43.9% of students who received extra time vs. 44.5% of those who had standard time and were accepted into medical school, different among those who received extra time compared to those who did not (16). Yet, students who tested with extra time performed less well on the USMLE Step examinations or repeated the exam and graduated at significantly lower rates. A recent study looked at MCAT vs. USMLE performance within cognitive (psychological, learning disorders, and ADHD) and noncognitive groups (physical disabilities, deaf and hard of hearing (DHOH), and others in this category) (12). Students with noncognitive disabilities scored lower on Step 1 than their non-disabled peers, yet their Step 2CK scores are within the same range as the nondisabled group (12). Students with cognitive disabilities score lower on both Step 1 and Step 2CK compared to students with noncognitive disabilities and students without disabilities (12). The reason behind this discrepancy is unknown and requires further investigation (12). Medical school educators and administrators need to better understand potential barriers to medical education for students with disabilities to develop evidence-based policies, procedures, and resources (16) (12). Academic measures, which count for numerical scores on in-house and standardized exams, for students with disabilities were lower and less likely to graduate. Yet, students' clinical performances were comparable to those without disabilities (16) (12). Current research also found that the magnitude of differences in clinical performance varied by type of disability (16) (12). For example, students presenting with psychological disabilities tended to perform lower clinically than others (20). To have a better understanding of how to support student performances with varying disabilities, more research is needed to understand the interplay between disability and performance differences to improve the medical education process for students with disabilities and information about the accommodations provided on the USMLE Step examinations and compare them with MCAT accommodations (16) (12). In Purkiss' et al.'s (2021) study, USMLE scores were compared to MCAT scores, yet whether those students receive accommodations on the USMLE exam is unknown (12). What was found was that student from the noncognitive disabled group (which encompass mobility, physical, chronic health, deaf and hard of hearing, and low vision) did score lower on USMLE Step 1 compared to the global population but performed the same on USMLE Step 2CK (12, 13). The cognitively disabled group (psychological, learning, and ADHD disabilities) scores were lower on USMLE Step 1 and Step 2CK than the global population (12, 13). There is a positive correlation between MCAT scores vs. USMLE scores, yet the study did not indicate whether the students studied did receive accommodations on that standardized exam (12, 13). Knowing this limitation could be helpful in narratively explaining why students with disabilities struggle on these exams.
In a study from 2013, clinical clerkship performance of students with protected disabilities from a mental impairment, but not from physical impairment, was below that of students without protected disabilities (20). However, the magnitude of the differences was small, and whether these differences present difficulties in practice is unknown (20). It is also important to note that early research from the 2000s focused on academic performances from a numeral standpoint (letter grades, step 1 scores) rather than clinical abilities. Studies indicate that care by physicians with disabilities allows for greater empathy of patients (2). While the difference in graduation rates between students with and without protected disabilities was more apparent than those without, the statistical significance was limited since the study was performed at a single institution and the student population was small (20). Reasons for differences during medical school and subsequent performance during and beyond residency training should be further assessed. As a starting point, as suggested by the Purkiss 2021 article, to continue to look at the association between MCAT and USMLE scores may better inform admissions committees with concerns regarding the academic performance of applicants with disabilities (12). Since the model conducted had a significant disability by MCAT interaction, showing that MCAT scores were related with similar changes in USMLE scores regardless of disability status (12).