PRECEDENTIAL

UNITED STATES COURT OF APPEALS

FOR THE THIRD CIRCUIT

______________

No. 20

- 1058

______________

JESSICA RAMSAY

v.

NATIONAL BOARD OF MEDICAL EXAMINERS,

Appellant

______________

On Appeal from the United States District Court for the Eastern District of Pennsylvania ( D.C. No

. 2

- 19

- cv

- 02002 )

District Judge: Honorable J. Curtis Joyner

______________

Argued Ju ly 1 , 2020

______________

Before: GREENAWAY, J R

., SHWARTZ, and RENDELL,

Circuit Judges

.

(Filed: July 3 1 , 20 20 )

______________2 Lawrence D. Berger

Reisman Carolla Gran & Zuba

19 Chestnut Street Haddonfield, NJ 08033

Mary C. Vargas [ARGUED] Stein & Vargas 10 G Street, N.E.

Suite 600 Washington, DC 20002

Counsel for Plaintiff

- Appellee Jessica Ramsay

Robert A. Burgoyne [ARGUED]

Caroline M. Mew

Perkins Coie 700 13th Street, N.W.

Suite 600 Washington, DC 20005

Alison R. Caditz

Perkins Coie

1201 Third Avenue

Suite 4900 Seattle, WA 98101

Counsel for Defendant

- Appellant National Board of

Medical Examiners3 ______________

OPINION

______________

SHWARTZ, Circuit Judge

.

Medical student Jessica Ramsay sought testing accommodations for dyslexia and attention deficit hyperactiv ity disorder (“ADHD”) from the National Board of Medical Examiners (“the Board”). T he Board denied her
request s
, and she sued under the Americans with Disabilities Act (“ADA”)

. The District Court granted a preliminary injunction, requiring the Board to provide her

accommodations . W e will affirm.

I

A

The Board administers the United States Medical Licensing Examination (“USMLE”). The USMLE has three
components , or “Steps

, ” that medical students must pass before they can apply for a medical license. Step 1 is a computer

based, multiple choice exam that assesses a student’s grasp of scientific concepts. S tudents typically take Step 1 before their final year of medical schoo l

. Step 2 has two parts: Clinical Knowledge (“CK”)

, a computer

- based, multiple choice exam

that assesses medical knowledge and clinical science, and

Clinical Skills (“CS”) that assesses students in a clinical setting

. Step 2 must be taken before graduation. Step 3 is a
computer

- based exam that assesses the application of medical4 and scientific knowledge to the practice of medicine. Step 3

must be taken before applying for a medical license.

Ramsay, while a thi rd

- year medical student at Western Michigan University (“WMed”), requested an accommodation

, namely extra testing time, for Step 1 and Step

2 CK . The basis of her request was that she had ADHD and dyslexia

. S he submitted to the Board :

• a diagnosis of AD HD and probable dyslexia by her family physician, Dr. Alan Smiy

, made when she was an undergraduate;

• r ecords of accommodations provided by her undergraduate institution and by WMed ;

• e valuations from Charles Livingston, a licensed social worker, who administered several assessments that supported a diagnosis of ADHD and a likelihood of dyslexia and showed, in his opinion, that Ramsay had

“ relatively low attention and concentration and v ery low processing speed

, ” although “[h] er native intelligence has been some compensation for low

abilities in the identified areas ”;

• h er MCAT scores, taken without accommodations, placing her in the 67th and 31st percentiles for verbal reasoning and writi ng, respectively ;

• a cademic records and other standardized test scores, taken without accommodations, showing a high level of achievement; and5 • a personal statement attesting that she struggled from an early age with maintaining concentration

, reading

, and writing, but that she achieved academic success through mitigating strategies

, informal

accommodations from teachers

, and accommodations from her undergraduate and medical schools

.

The Board provided Ramsay’s materials to an outside reviewer, Dr. Stephen Zecker, who opined that Ramsay was not “substantially limited in functioning in a manner that warrants accommodations.” App. 766. The Board also

reviewed Ramsay’s documentation and , noting her record of achievement without accommodations, concluded that the

documents did not “ demonstrate a record of chronic and pervasive problems with inattention, impulsivity, behavioral regulation, or distractibility that has substantially impaired [her] functioning during [her] development or currently

. ” App.

1126. Based on Dr. Zecker’s recommendation and the Board’s review of Ramsay’s materials, the Board denied her request.

Thereafter, Ramsay took Step 1 without

accommodations in her third y ear
, but she failed by one poin t.
Because WMed requires students to pass Step 1 by the beginning of their fourth year

, she took a leave of absenc e.

Ramsay renewed her request for extra testing time and

submitted an evaluation and test data from neuropsychologist

Dr. Alan Lewandowski

. Dr. Lewandowski met with Ramsay,

conducted assessments, found that she had abnormal functionalities in thinking, processing speed, attention, and sequencing , and concluded that she had ADHD

. Ramsay also submitted a letter from her treating psychiatrist, Dr. Bruce Ruekberg, who concurred with Mr. Livingston’s and Dr.6 Lewandowski’s assessments, stating that she had abnormal scanning and processing speed that impaired her reading and written expr ession

. The Board denied her request for extra testing time, again concluding that she had not shown she was substantially limited in any functions as compared to most people. 1

Ramsay sought reconsideration of the Board’s denial.

As additional support, she provided an evaluation by Dr. Robert D. Smith, a psychologist and neuropsychologist . Dr. Smith met with Ramsay, reviewed her records, and performed

similar assessments. He report ed that the assessments revealed that she had abnormally low abilities in processing information, writing, and reading, indicating dyslexia and

ADHD. Among other things, his testing revealed that Ramsay, as compared to others in her age group, was in the fourth percentile in reading comprehension and fluency, second percentile in word reading speed, and first percentile in oral reading fluency.

The Board provided Ramsay’s file to outside expert Dr. Benjamin Lovett

, who concluded that Ramsay did not show poor academic skills or impairments compared to the general population and thus lacked a condition that would warrant
accommodations

. Based on Dr. Lovett’s recommendation and further review, the Board denied Ramsay’s request for

recon sideration.

1 The Board granted Ramsay’s requests for additional break time and a separate testing room as accommodations for migraines and deep vein thrombosis.7 B

Ramsay sued the Board in May 2019, alleging that it

had violated the ADA

. 2 The next month, WMed informed Ramsay that it could extend her leave only until March 2020, “with the expectation that [she] will sit for the USM L E Step 1

exam i n a manner that allows [her] to return to the WMed curriculum by that date.” App. 1520. WMed informed Ramsay that i f she did not pass Step 1 and return by March

2020

, she would be dismissed or could voluntarily withdraw

, but re admission would not be guarantee d. 3 Ramsay accepted
WMed’s conditional extension of leave.

Because Ramsay had to pass Step 1 to avoid dismissal

, she sought a preliminary injunction to require the Board to grant her accommodation s. The District Court held a three

- day

evi dentiary hearing featuring testimony from , among others, Ramsay, Dr. Smith, Dr. Zecker, and Dr. Lovett.

For the reasons explained in its careful and thorough opinion, t he District Court granted Ramsay a preliminary injunction and required the Board to provide Ramsay with

double the testing time on Step 1, Step 2 CK, any written or reading portions of Step 2 CS, and Step 3. Ramsay v. Nat’l

2 Ramsay also alleged a Rehabilitation Act claim, 29 U.S.C. § 794, but the parties agree that only her A DA claim is relevant to the preliminary injunction.

3 The Board contends that Ramsay only had to take, not pass, Step 1 to remain enrolled in school. Given that WMed students must pass Step 1 by the beginning of their fourth year

, however, Rams a y could not continue into her fourth year at WMed without passing Step 1

.8 Bd. of Med. Exam’rs , No. 19

- CV

- 2002, 2019 WL 7372508 (E.D. Pa. Dec. 31, 2019). The Cour t found that all the experts were qualified, but that the testimony and reports of the experts who met with Ramsay were more persuasive. Id. at *17. Those experts stat ed that their assessments and evaluations all

showed that Ramsay had low reading, writi ng, and processing

abilities. Id. at *15

- 16. The Court also found that the Board’s experts’ analyses contradicted applicable regulations by focusing too much on Ramsay’s academic achievements, substituting their own opinions for those of experts who met with Ramsay, and plac ing too demanding a burden on Ramsay.

Id. at *17

- 18. Based on this evidence and the governing law

, the Court found that Ramsay had a disability under the ADA.

Id. at *18.

T he Court also found that : (1) Ramsay established irreparable harm because she would likely be forced to withdraw from WMed if she could not take Step 1 with accommodations and pass, (2) the balance of equities tipped in her favor because granting her accommodations would not

undermine the Board’s interests in fair and accurate testing, and (3) it was in the public interest for the ADA to be followed

and to increase the number of physicians

. Id. at * 18

- 19. The Board appeals

. 4

4 After the Board filed its appeal, Ramsay passed Step 1 with accommodations. This appeal, however, is not moot because (1) the District Court’s injunction extends to Steps 2 and 3, which Ramsay has not yet taken, and (2) as to Step 1, if

we vacated the in

junction, the Board could invalidate her score or prevent her from submitting the score to residency

program s. See Chafin v. Chafin , 568 U.S. 165, 172 (2013)9 II 5

In issuing a preliminary injunction, a district cour t
consider s four factors:

(1) the likelihood that the plaintiff will prevail on the merits at final hearing; (2) the extent to which the plaintiff is being irreparably harmed by the conduct complained of; (3) the extent to which the defendant will suffer irreparable harm if the

pre liminary injunction is issued; and (4) [that] the public interest [weighs in favor of granting the injunction].

Greater Phila. Chamber of Commerce v. City of Philadelphia

, 949 F.3d 116, 133 (3d Cir. 2020) (alterations in original) (quoting A m. Tel. & Tel

. Co. v. Winback & Conserve Program, Inc. , 42 F.3d 1421, 1427 (3d Cir. 1994)).

(explaining that a case is not moot if the parties “ ‘ continue to have a personal stake’ in the ul timate disposition of the

lawsuit ” (quoting Lewis v. Cont ’ l Bank Corp. , 494 U.S. 472,

4 78 (1990) ))

.

5 The District Court had jurisdiction under 28 U.S.C. § 1331. We have jurisdiction under 28 U.S.C. § 1292(a)(1). “We employ a tripartite standard of revie w for

. . . preliminary injunctions. We review the District Court’s findings of fact for clear error. Legal conclusions are assessed de novo. The ultimate decision to grant or deny the injunction is reviewed
for abuse of discretion.” Ass’n of N.J. Rifl e & Pistol Clubs, Inc. v. Att’y Gen. N.J. , 910 F.3d 106, 114 (3d Cir. 2018) (omission in original) (quoting K.A. ex rel. Ayers v. Pocono

Mountain Sch. Dist. , 710 F.3d 99, 105 (3d Cir. 2013)).10 A

We first address Ramsay’s likelihood of success on the

merits of her ADA claim. “ On this factor, a sufficient degree of success for a strong showing exists if there is a reasonable chance or probability

, of winning” on her ADA claim. Ass’n of N.J. Rifle & Pistol Clubs, Inc. v. Att’y Gen. N.J. , 910 F.3d 106, 11 5 (3d Cir. 2018) (internal quotation marks and citation omitted). The ADA provides in relevant part :

Any perso n that offers examinations

. . . related to applications, licensing, certification, or credentialing for

. . . professional

. . . purposes shall offer such examinations

. . . in a place and manner accessible to persons with disabilities or offer alternative accessible arrangements for

such individuals.

42 U.S.C. § 12189. The issue here is whether Ramsay has a “disability ” that entitles her to an accommodation. Ramsay

, 2019 WL 7372508, at *8.

The ADA defines “disability” in relevant part as “a physical or mental impairment that substantially limits one or more major life activities of such individual.” 42 U.S.C. § 12102(1) (A)

. We construe the term “disability” broadly. I d. § 12102(4)(A). As to the term “impairment,” the applicable Department of Justice (“DOJ”) regulations 6 provide that the

6 In 42 U.S.C. §§ 12186(b) and 12205a, the ADA

authorizes DOJ to issue regulations implementing the public11 term “physical or mental impairment” includes ADHD and “dyslexia and other specific learning disabilities.” 28 C.F.R. § 36.105(b)(2). As to “life activities

, ” the ADA provides that

“ m ajor life activities include

. . . reading, concentrating, thinking, communicating, and working.” 42 U.S.C. § 12102(2)(A). Finally, the regulations explain that “[a] n impairment is a disabil ity

. . . if it substantially limits the ability of an individual to perform a major life activity as compared to most people in the general population. ” 28 C.F.R. § 36.105(d)(1)(v) . Accordingly, “‘ [ n ]ot every impairment will constitute a disability

. . . , ’ but [an impairment] will meet the

definition [of disability] if ‘ it substantially limits the ability of an individual to perform a major life activity as compared to most people in the general population. ’ ” J.D. by Doherty v. Colonial Williamsburg Fo und. , 925 F.3d 663, 670 (4th Cir. 2019) (quoting 28 C.F.R. § 36.105(d)(1)(v) )

.

1

The Board argues that the District Court did not determine that Ramsay is substantially limited in comparison

accommodations provisions of the ADA. Such re g ulations
have “ the force and effect of law

. ” See PDR Network, LLC v. Carlton & Harris Chiropractic, Inc.

, 139 S. Ct. 2051 , 2055 (2019) (quoting Perez v. Mortg. Bankers Ass’n

, 575 U.S. 92

, 97 (2015)); accord Pa. Dep’t of Human Servs. v. United States

, 897 F.3d 497, 505 (3d Cir. 2018). The regulations “ are entitled

to substantial deference

. ” Helen L. v. DiDario , 46 F.3d 325, 331 (3d Cir. 1995)

.12 to most people in the general population. 7 We first address the concept of “most people in the general population” in the learning disability context

. In general,

[t] he comparison to most people in the general population

. . . mean [s] a comparison to other people in the general population, not a comparis on to those similarly situated. For example, the ability of an individual with an amputated limb to perform a major life activity is compared to other people in the general population, not to other amputees

. This does not

mea n that disability cannot be s hown where an impairment, such as a learning disability, is clinically diagnosed based in part on a disparity

between an individual ’ s aptitude and that

individual ’ s actual versus expected achievement, taking into account the person ’ s chronological age, measured intelligence, and age

- appropriate

7 Relatedly, the Board argues that the District Court improperly considered Ramsay’s work ethic and study habits, which the Board argues are improper considerations because “working hard does not show that [Ramsay] is substantially imp aired.” Appellant’s Br. at 47. However, “[t] he determination of whether an impairment substantially limits a major life activity shall be made without regard to the ameliorative effects of mitigating measures. ” 28 C.F.R. § 36.105 (d)(1)(viii). According ly, in deciding whether Ramsay was disabled, the Court could appropriately consider and discount that she compensated for her very weak reading and writing abilities by devoting more effort to her assignments

than most students.13 education. Individuals diagnosed with dyslexia

or other learning disabilities will typically be substantially limited in performing activities such as learning, reading, and thinking when

com pared to most people in the general population

. . . .

Regulations t o Implement the Equal Employment Provisions

of the Americans w ith Disabilities Act, as Amended

, 76 F ed.

R eg. 16

, 978 , 17,009 (Mar. 25, 2011) (explanation by the Equal Employment Opportunit y Commission (“EEOC”)); see Amendment of Americans w ith Disabilities Act Title II and

Title III Regulations t o Implement ADA Amendments Act of

2008

, 81 F ed. R eg. 53

, 204 , 53,230 (Aug. 11, 2016) (DOJ “concur[ring] with” EEOC’s “view”). 8 Thus, a clinical

di agnos is of a learning disability is typically based upon a comparison between the individual and others in the general population who are of similar age and have received age

appropriate education.

Here, the District Court relied on such diagnostic information to conclude that Ramsay had ADHD and dyslexia

8 “[T] he preamble to a regu lation may be used as an aid in determining the meaning of a regulation.” Conn. Gen. Life

Ins. Co. v. Comm’r , 177 F.3d 136, 145 (3d Cir. 1999) (quoting Commonwealth of Pa. Dep’t of Pub. Welfare v. U.S. Dep’t of

Health & Human Servs. , 101 F.3d 939, 944 n.4 (3d Cir. 1996));

see also Helen Mining Co. v. Dir. OWCP , 650 F.3d 248, 257 (3d Cir. 2011) (holding that an administrative law judge’s

“ reference to the preamble to the regulations

. . . unquestionably supports the reasonableness of his decision to assign less weight to [an expert’s] opinion ”)

.14 that cause d her to read and write with more difficulty than most people. For example, Dr. Smith ’s and Dr. Lewandowski ’s diagnostic assessments showed that Ramsay had abnormal functionalities in thinking, processing speed, attention, and sequencing. Indeed, some of the reading tests Dr

. Smith

administered placed Ramsay in less than the fifth percentile as compared to individuals her age. This is exactly the type of

d ata DOJ contemplates as showing a learning disability that substantially limits an individual as compared to others in the general population. Equal Employment Provisions

, 76 F ed.

R eg. at 17,009; Title II and Title III Regulations

, 81 F ed. R eg. at 53,230. Further, Ramsay explained in her personal

statement that she had struggled with reading and writing tasks in comparison to her classmates since elementary school. Thus, the Court ’s f

inding that Ramsay’s ADHD and dyslexia constituted a disability was based on evidence that these

conditions substantially limit her reading and writing in comparison to most people. See Pryer v. C.O. 3 Slavic , 251 F.3d 448, 453 n.4 (3d Cir. 2001) (inferring the district court’s reasoning wher e it was “ otherwise apparent from the record”). 9

Moreover, the regulations provide that the “substantially limits” inquiry “should not demand extensive analysis,” 28 C.F.R. § 36.105(d)(1)(ii), and that “[t]he comparison of an individual’s performance of a major life

9 We further disagree with the Board ’s contention that

t he District Court never found that Ramsay was substantially

limited as compared to the general population because when the Court concluded that Ramsay was disabled, it defined disability as a substantial limitation as compared to most people in the general population. Ramsay , 2019 WL 7372508,

at *7

- 8

.15 activity to the performance of the same major life activity by most people in the general population usually will not require scientific, medical, or statistical evidence,” id. § 36.105(d)(1)(vii). Accordingly, the District Court’s reliance

on evidence that Ramsay’s reading , processing, and writing

skills were abnormal ly low by multiple measures provided a sufficient comparison of her abilities to those of the general population to support the finding of disability

. 10

2

Next, the Board argues that the District Court erred by giving “considerable weight” to Ramsay’s past accommodations when determining that she has a disability. Appellant’s Br. at 45 (quoting 28 C.F.R. § 36.309(b)(1)(v)). According to the Board, a court should consider past accommodations only after finding the individual is disabled. This argument fails.

T he regulation defining disability , § 36.105

, does not bar consideration of past accommodations. Indeed,

10 The Board relies on Bibber v. National Board o f Osteopat hic Medical Examiner, Inc. , Civ. A

. No. 15

- 4987

, 2016 WL 1404157 (E.D. Pa. Apr. 11, 2016), but it is distinguishable. There, the district court held that the plaintiff
was not disabled because “ a mountain of evidence ,” including some of the same diagnosti c assessments that Ramsay took,

“ suggest [ed] that Bibber ’ s reading and processing abilities [were] average when compared to the general population. ” Id. at *8. In contrast, Ramsay’s scores on the same assessments were lower, and she explained at the hear ing how she reads in a manner that is different from the average person.16 § 36.309(b)(1)(v) provides that “[w] hen considering requests

for

. . . accommodations

. . . the [testing] entity gives considerable weight to documentation of
past

. . . accommodations

. ” Moreover, as the preamble to the applicable regulations states, “ a recent history of past

accommodations is critical to an understanding of the applicant ’ s disability and the appropriateness of testing

accommodations. ” Nondiscrimination on the Basis of Disability by Public Accommodations and in Commercial

Facilities

, 75 Fed. Reg. 56,236, 56,29 8 (Sept. 15, 2 010) (to be codified at 28 C.F.R. pt. 36)

. Thus, the District Court did not err in considering Ramsay’s past accommodations

.

3

T he Board also argues that the District Court wrongly

believed that the statute and regulations compel led it to defer to experts who met with and tested Ramsay. While t he Court viewed Ramsay’s experts more favorably and found the Board’s experts unpersuasive , there is no indication that the

Court believed that it was compelled to defer to Ramsay’s
experts . Rather, the Court discounted the Board’s experts because they (1) never met with Ramsay, (2) engaged in too demanding an analysis of whether Ramsay had a disability

, and (3) focused too much on Ramsay’s academic achievements. Ramsay , 2019 WL 7372508, at *17

- 18. The Court’s reasoning

was within its discretion and supported by the regulations.

First, it is within the trial judge’s discretion to credit a physician with firsthand observations of a patient over one who only reviewed the patient ’ s records. See United States v. Olhovsky , 562 F.3d 530, 548

- 49 (3d Cir. 2009). Such a

p rofessional has the benefit of seeing how the patient actually17 acts and speaks and provides a perspective not limited to the

cold record. This principle is not unlike the deference a n appellate court gives to a trial court who physically sees a

witness. Cooper v. Harris , 137 S. Ct. 1455, 1474 (2017). This is why w e rarely second

- guess a district court’s weighing of

evidence

, s ee, e.g.
, United States v. Turner , 718 F.3d 226, 231 (3d Cir. 2013) , and why it makes sense for the District Court to credit the professionals who personally met with Rams a y

.

Second, the regulations mandate that “[t] he determination of whether an impairment substantially limits a major life activity requires an individualized assessment. ” 28 C.F.R. § 36.105(d)(1)( vi). S uch assessments benefit from the reports of professional s who know or ha ve personally

examined the individual. Because such examinations allow the professional to evaluate the individual’s behavior, effort, and candor, DOJ understandably has stated that “ [r] eports from experts who have personal familiarity with the candidate

sh ould take precedence over those from

. . . reviewers for testing agencies, who have never personally met the candidate or conducted the requisite assessments for diagnosis and

treatment. ” Nondiscrimination on the Basis of Disability, 75 Fed. Reg. at 56,29 7. As a result, DOJ has directed that testing entities “shall generally accept” “ documentation provided by a qualified professional who has made an individualized assessment of an applicant that supports the need for the modification, accommodation, or ai d requested

. . . and provide the accommodation

. ” Id. Thus, the Court’s decision18 to weigh Ramsay’s experts more favorabl y than those of the Board was consistent with DOJ regulations. 11

Third

, “the threshold issue of whether an impairment substantially limits a major life activity should not demand extensive analysis.” 28 C.F.R. § 36.105(d)(1)(ii)

. T he Court could reasonably have conclude d that the Board’s experts were

too deman d ing in what they required to prove a disabilit y , for example

, by demanding evidence of a lifetime of academic struggles, and “substitut ing their own opinions ” for those of Ramsay’s healthcare provider s

. Ramsay , 2019 WL 7372508,

at *17

. In fact, the Board’s reliance on Ramsay’s academic achievement was contrary to the regulations that explain that “someone with a learning disability may achieve a high level of academic success, but may nevertheless be substantially

limited in one or mor e major life activities, including, but not limited to, reading, writing, speaking, or learning because of the additional time or effort he or she must spend to read, write,

11 The Board argues before us that a 2011 settlement agreement between it and DOJ eliminates the preference to be given to professionals who personally examined the individual. The Board did not make this argument before the District

Court

, so we do not fau lt the Court for not considering it. In any event, the Board is wrong. First, the settlement addresses the Board’s obligations and not a court’s considerations under the regulations when deciding whether an individual has a disability. Second, while the agreement states that the Board need not defer to the conclusions of such professionals, that does not mean it is relieved of showing in litigation why those professionals are unworthy of credence . Third, even if the agreement had any bearing on the regulations, which it does not, it expired in 2014.19 speak, or learn compared to most people.” 28 C.F.R. § 36.105(d)(3)(iii). 12 Becau se Rams a y’s high academic performance does not foreclose her from having a disability

, t he Court reasonably discounted the Board’s expert s’ opinions,

which focused mostly on Ramsay’s academic accomplishments and ignored evidence of her limitations

. Ramsay , 2019 WL 7372508, at *18.

In sum , n othing in the District Court’s discussion

indicates that it held that the statute and regulations “compel” deference to Ramsay’s experts. Rather, the Court found that Ramsay’s experts provided facts more probati ve to the relevant inquiries under the ADA

, and its decision to view these witnesses more favorably is consistent with the regulations

. Thus, we will not disturb how the Court chose to weigh

evidence

.

12 When discussi ng this proposition, the Court quoted 29 C.F.R. § 1630.2(j)(4)(iii), promulgated by the EEOC, which does not implement the operative ADA title here. 42 U.S.C. § 12116 (providing EEOC authority to implement the employment provisions of the ADA). Nonetheless, DOJ has issued an identical regulation. Compare 28 C.F.R. § 36.105(d)(3)(iii), with 29 C.F.R. § 1630.2(j)(4)(iii). Thus,

there was no legal error “infecting” the Court’s weighing of
experts. Bedrosian v. United States , 912 F.3d 144, 152 (3d Cir. 2018) (quoting U.S. Bank Nat’l Ass ’n ex rel. CWCapital Asset Mgmt., LLC v. Vill. at Lakeridge, LLC , 138 S. Ct. 960, 968

n.7 (2018)).20 4

The additional errors the Board identifies in the Court’s factual findings do not amount to clear error. “A finding of fact is clearly erroneous when it is completely devoid of minimum evidentiary support displaying some hue of credibility or bears no rational relationship to the supportive evidentiary data.” VICI Racing, LLC v. T

- Mobile USA, Inc.

, 763 F.3d 273, 283 (3d Cir. 2014) (internal quotation marks and citation omitted)

. W e examine the entire record to determine whether there is evidentiary support for a finding, not just the

evidence a district court cites. See N.J. Rifle , 910 F.3d at 120

n.24.

First, the Board argues that the District Court erred in finding that the Board ’s consultants found that Dr. Smith ’s

assessments were valid and credible. Con trary to the Board’s assertion, t he record supports th e Court’s finding. B oth of the
Board’s consultants testified that they had no reason to doubt that the assessments were properly administered , that the results were accurate, and that the data could be useful, although they disagreed with Dr. Smith’s interpretation of the results. The credibility of evidence is different from the

inferences a factfinder can draw from that evidence , so the Court’s finding that all experts agreed the assessments were

credible was supported by the consultants’ testimony, even if

the Board’s consultants reached different conclusion s from the

test results themselves

. 13

13 In making this finding, the District Court misquoted one piece of evidence, a letter from the Board. The Court stated that the Board found Ramsay’s expert assessment to be21 Second, the Board argues that the District Court erred

in finding that Ramsay could not finish reading and had to guess on about a third of the questions on Step 1 because the time Ramsay spent on each question shows that “ she had time

to read every question .” Appellant’s Br. at 61 (emphasis omitted) (citing Ra msay , 2019 WL 7372508, at *3). The

record does not contradict the Court’s finding. T he Board’s

evidence does not indicate how much time Ramsay spent reading each question. Rather, it shows only that she spent, on

average, seventeen seconds more on the questions she got

incorrect. Further, Ramsay testified that she took a pass through the questions before answering them, answered the ones she felt she could, and repeated that strategy until she was left with a few questions she could not answer even after multiple reads. Her strategy provides a reasonable explanation for why the time spent on correct versus incorrect answers was

similar. T he Court was free to credit Ramsay’s testimony over

the inferences that the Board argued should be drawn from its

measurements. See Cloverland

- Green Spring Dairies, Inc. v.

P a. Milk Mk t g. Bd. , 462 F.3d 249, 271 (3d Cir. 2006) (“ Where there are two permissible views of the evidence, the

factfinder ’ s choice between them cannot be clearly erroneous.” (quoting Scully v. US WATS, Inc. , 238 F.3d 497, 506 (3d Cir. 2001) )).

valid. Ramsay , 2019 WL 7372508, at *4 (quoting App. 1512). The letter, however, w as referring to Ramsay’s expert accepting the assessments as valid. Accordingly, the letter does not support the Court’s finding because it does not embody the Board’s view. Nonetheless, other evidence in the record supports the finding, as explained abo ve, so there is no

clear error. N.J. Rifle , 910 F.3d at 120 n.24.22 Finally, the Board argues that the District Court erred in finding that Ramsay had received informal accommodations in her early school years. Ramsay testified about , and her mother relayed to Dr. Smith information concerning

, these informal

accommodation s

. While the Board assert s that there is no

written record of these informal accommodations, Ramsay’s corroborated testimony provided “ minimum evidentiary support” for the Court’s finding, so there was no clear error. 14 VICI Racing , 763 F.3d at 283 (cita tion omitted)

.

B

We next determine whether Ramsay proved irreparable

harm. “[T]o show irreparable harm a plaintiff must demonstrate potential harm which cannot be redressed by a legal or an equitable remedy following a trial.” Acierno v. New Castle C ount y , 40 F.3d 645, 653 (3d Cir. 1994) (internal quotation marks and citation omitted)

. T he harm must be

“ likely ” to occur “ in the absence of an injunction.” Ferring

Pharms. , Inc. v. Watson Pharms., Inc. , 765 F.3d 205, 217 n.11 (3d Cir. 2014) (emphasis omitted) (quoting Winter v. Nat. Res. Def. Council, Inc. , 555 U.S. 7, 22 (2008)).

The D istrict Court had a basis to conclude that Ramsay would be irreparabl y harmed absent an injunction. T he Court

could reasonabl y conclude that given Ramsay’s disability and

that she had previously failed Step 1, she likely would fail

14 Aside from her mother’s statements to Dr. Smith, Ramsay’s report cards from elementary school are also consistent with her testimony because her teachers noted she

needed “help

. . . with the switching of letters

, ” App

. 871

, and “to focus on getting her work done on time

, ” App

. 875

.23 again and be forced to leave medical school

. 15 Ramsay

, 2019

WL 7372508 , at *18. Her termination from medical school and its consequences could not later “ be redressed by a legal or an equitable remedy.” Ac ierno , 40 F.3d at 653 (citation omitted)

. No damages remedy is available under the ADA. 42 U.S.C. § 12188(a)(1) (providing that the only remedies available in an ADA action are those in § 2000a

- 3(a)); id. § 2000a

- 3(a) (providing for injunctive relief). Furthermore,

because WMed is not a party to this case, the Court could not require it to reinstate her , and t he Board presents no theory for

how the Board could redress the termination of Ramsay’s medical education. Moreover, an examiner ’ s refusal to provide accommodations can cause the exam

- taker irreparable harm because doing so jeopardize s her “ opportunity to pursue her chosen profession. ” Eny art v. Nat’l Conf. of Bar Exam’rs

, 630 F.3d 1153, 1166 (9th Cir. 2011) ; accord Doe v. P a. State

Univ. , 276 F. Supp. 3d 300, 313

- 14 (M.D. Pa. 2017) ( holding

that gap in medical school education and likelihood that the student could not gain acceptance to an other school constituted irreparable harm)

. Accordingly, the District Court correctly

concluded that Ramsay established she would be irreparabl y harm ed absent an injunction

.

15 The letter from WMed provided a basis for the

District Court to conclude that she would be dismissed from the medical school if she did not pass Step 1. The letter offered to extend Ramsay’s leave until “ March 2, 2020, with the expectation that [she] will sit for the USM L E Step 1 exam in a manner that allows [her] to return to ” WMed

. App. 1520

. As noted above, WMed students must pass Step 1 by the beginning of their fourth year. Thus, to return to school,

Rams a y had to pass Step 1.24 C

We next consider how the District Court “balanc [ed] the parties’ relative harms; that is, the potential injury to the plaintiff[] without this injunction versus the potential injury to the defendant with it in place.” Issa v. Sch. Dist. of Lancaster

, 847 F.3d 121, 143 (3d Cir. 2017). In balancing the harms, the
Court noted the Board’s “concern for the fulfillment of its mission to provide [qualified] physicians

, ” Ramsay

, 2019 WL

7372508 , at *19

, and that accommodations “can affect the comparability of the resulting scores and scores achieved under

sta ndard testing conditions

, ” i d. at *4 (quoting App. 931)

. Nonetheless, the Court appropriately reasoned that granting a preliminary injunction would not undermine the Board’s

mission because the injunction would give Ramsay only “ the opportunity to move fo rward ” in her medical career “ should she succeed in passing her examinations with appropriate

accommodations. ” Id. at *19 (emphasis omitted). Moreover, the Board’s concerns regarding impacts from undeserved accommodations do not apply here because Ramsay has shown

a reasonable likelihood that she deserves accommodations. Cf.

Issa , 847 F.3d at 143 (holding that a defendant could not assert

an interest in continuing to violate a civil rights statute).

D

Finally, we consider the District Court’s finding that

“ the public interest favors this preliminary injunction .” Id.

The Court concluded that an injunction furthers the public

interest in ADA complianc e and serves to increas e the number of qualified physicians

. Ramsay , 2019 WL 7372508, at *19. We agree

. “I n enacting the ADA, Congress demonstrated its view that the public has an interest in ensuring the eradication25 of discrimination on the basis of disabilities. ” Enyart , 630 F.3d at 1167; see Issa

, 8 47 F.3d at 143 (concluding that it was in the public inter est for covered entities to comply with a civil rights statute). Further, the injunction allows Ramsay to continue her

medical education and therefore serves the public interest in training more physicians. “ Although it is true that the public

also has a n interest in ensuring the integrity of licensing

exams, ” Enyart , 630 F.3d at 1167, Ramsay has shown a

reasonable likelihood that the ADA affords her accommodations, and there is no evidence that providing her the requested accommodations will jeopardize t he test’s integrity . Thus, the public interest weighs in favor of an injunction.

III

For the foregoing reasons, we will affirm the District

Court’s preliminary injunction

. 16

16 Given our conclusion that the District Court correctly held that Ramsay has shown a likelihood of success on the

merits of her cl aim that she has a disability for which she is entitled to accommodations, we will affirm the preliminary injunction requiring the Board to provide the accommodations

on Step 2 CK, any written or reading portions of Step 2 CS, and Step 3.