Exploring How Case-Based Learning Addresses Disability.

Abstract

Purpose: In response to the health care inequities faced by people with disability laid bare by the COVID-19 pandemic, Doebrich et al propose the importance of a disability-conscious medical education that engages with critical disability studies (CDS). 1 CDS is an academic field driven by people with disabilities that resists ableism and positions disability as a cultural, social, political, and historical identity arising from human variation. 1 In 2021, Iezzoni et al reported that over 80% of surveyed physicians hold ableist beliefs (defined as the superior valuation of nondisabled bodies/minds over disabled ones). 1,2 This clearly impacts the health and well-being of the 1 in 4 U.S. noninstitutionalized adults who have self-reported disability. 1–3 Consequently, people with disability face significant health disparities caused by systemic ableism. 1 Through the CDS perspective, it becomes clear that ableism is entrenched in medical culture and education, and yet, as of 2015, about half of surveyed medical schools did not have disability-related curriculum. 2,3 Despite a recent curricular revision at our medical school, both students and faculty raised concerns about disability representation in our curricular materials, including case-based learning (CBL). Given that other inquiry-based pedagogies have been shown to undermine patient-centered care and overemphasize the biomedical model, 4 it is imperative to evaluate the CBL curriculum. If disability is inadequately addressed in CBL, it allows harmful assumptions of disability to go unchallenged (a hidden curriculum), which can fuel bias and ableism. Method: Researchers conducted a qualitative analysis of 53 preclerkship CBL cases during 2021 at one medical school. A directed content analysis approach was employed to develop a codebook based on case examination and review of CDS literature. 5 Toward the end of the codebook development process, 5 “Gestalt” codes encompassing broad, critical themes related to CDS concepts that could either be present in, or missing from, an entire case were added. All cases were independently coded by 2 trained student researchers, and coding accuracy was assessed for consistency by the research team. Results: The word disability was included in 4 of 53 cases. Analysis revealed no examples of text that challenged conventional views of disability. Among the 4 cases that included disability, coding identified 2 cases that demonstrated concepts reinforcing negative attitudes of disability. Across all cases, coding revealed 332 examples of assumptions consistent with ableism. Discussion: Disability is rarely overtly addressed in our CBL materials as coding efforts revealed only 4 instances of disability content in cases deployed in the preclerkship phase of our medical school curriculum. In addition, there is no acknowledgment of disability as a social/cultural identity and no examples of text that challenge conventional views of disability from a CDS perspective. By inadequately addressing disability in the CBL cases, ample opportunities exist for misguided assumptions of disability to enter the classroom unchallenged. This remains particularly relevant given that ableism permeates our dominant culture, ubiquitously enforcing stereotypes and misconceptions of disability, which then affect the quality and type of care that people with disability receive, perpetuating a hidden curriculum. Thorough review of the cases helped identify opportunities to include CDS perspectives of disability in CBL to better prepare students to care for all their future patients. Significance: Even with recent thorough curricular revisions, our school overlooked CDS, and we fear many others have as well. This omission can perpetuate a hidden curriculum that fuels health inequities for people with disability. Our approach to CBL case review may allow other medical schools to assess their own curricular materials and identify opportunities to remove bias and infuse CDS perspectives in the curriculum.