Reasonable accommodation: how much and how far?

Sometimes I wonder what it is like to hear perfectly. I also wonder what would have become of me if I could. Would I have had the same resolve to become a doctor? Does a disability hold a person back, or does it push them forward? In 1990, the Americans with Disabilities Act was passed. Even though the Rehabilitation Act of 19731 contained the basic laws requiring provision of the services I would need to complete medical school, the Americans with Disabilities Act made those services more readily available. While in medical school at the University of California-Los Angeles (UCLA), I was provided with sign language interpreters for classroom lectures, clinical rotations, and all other activities requiring communication in a group. When I am talking with someone, my lip-reading skills are sufficient to ensure successful communication, but in a group, by the time I locate to the sound of a particular person talking or figure out from the body language of others who is speaking, the opportunity to read the speaker's lips has often passed. It may seem unlikely and surprising to many readers that I would choose a career as a physician. Perhaps my hearing impairment is seen as something incompatible with the profession. My father is a physician, as are all of my paternal uncles. From their example, I knew that I wanted to be able to help others. My family unwaveringly supported me in each step of the process toward achieving this goal. Providing interpreting services for my training was and continues to be expensive. I still use interpreting services now, during my residency, at the Oregon Health Sciences University, Portland. These services have been provided at no cost to me, largely because of the requirements of the Americans with Disabilities Act, which states, “the Nation's proper goals regarding individuals with disabilities are to assure equality of opportunity.”2 That statement is from the original bill; in more recent times, however, there has begun a general questioning of who qualifies for services under the law. In our ever-changing climate of health care, costs, including accommodations for the disabled, are scrutinized. But is it truly cost-effective to deny someone reasonable accommodation based on cost alone? My answer would be that it depends on the person and the circumstances. We must think about the long-term “return on investment” when making this evaluation. I am often asked to speak to groups of deaf children in elementary, middle, and high schools. Students have approached me after such talks to tell me that not only did they think it was impossible for deaf people to become doctors, but they were also unsure of their ability to secure a professional job in the future. Some students have told me that now they are willing to face the nay-sayers and to give it a try. I believe this is due, in part, to the fact that their expectations have been raised by exposure to someone who has successfully pursued a competitive profession. How much does it cost to raise expectations? One particular boy stands out in my mind. He told me that he thought he might be relegated to factory work because he was deaf, but now he wanted to go to college. It is worthwhile to note that deaf people, because of their disability, qualify for Social Security Insurance benefits, as well as many other public assistance programs. How much money do we, as a society, save when one deaf person embarks on a career rather than receiving public benefits? I did not have the luxury of deaf role models, but I am determined to give that chance to other deaf children. Under the public accommodation title of the Americans with Disabilities Act, physicians, hospitals, and medical offices are mandated to provide sign language interpreters to deaf consumers when it is required to ensure effective communication.3 From educated guesses of people in the field of interpreter referral, it can be estimated that 1,500 hours of medical interpreting services are provided per month in the Washington, DC, area alone (J Bailey, president of Sign Language Associates, Inc, Washington, DC, oral communication, July 1999). Would it be more cost-effective if a physician were able to communicate with deaf patients directly, even if it meant paying for interpreter services during that particular physician's training? Deaf people have told me alarming stories of repeatedly asking that an interpreter be provided at their doctor's office, only to have physicians turn down their request. Physicians all owe an economic debt to the American public. Teaching hospitals are given substantial government funding for each resident trained. For the help in financing their education and training, physicians also owe a debt of gratitude. I have a deeply felt sense of duty and obligation because I am aware of the additional investment that was made on my behalf, and I am honored to share the outcome of that investment with my patients. Economic issues aside, is it practical for patients to be seen by a deaf physician? Will the communication barrier compromise their quality of care? These are fair questions and should be addressed on an individual basis during the evaluation and screening process for admission to medical school. Although I cannot answer for every person with a disability, I can answer for my own situation. I picked a specialty I felt was compatible with my disability. Dermatology is a visual field, and I am in my element when relying on visual information and available environmental cues. As for my level of patient care, as yet, I have received no complaints. Ironically, my patients tell me that they feel I truly “listen” to them. This is probably because I must look patients directly in the face while lipreading, and I attend to every word they say. When I introduce myself to my patients, I explain my deafness and how we can communicate effectively. Patients, who are, by definition, vulnerable in some way, understand my vulnerability. Some patients feel that in their difficult times, it is easier to relate to a physician who is not “perfect.” The greatest opposition that I have faced has been from colleagues rather than patients. Some have told me outright that I would not be able to become a doctor, whereas others have openly expressed their desire to keep me in certain specialties so that my contact with the public will be diminished. None of these opinions suppressed my desire; rather, they have made me that much more determined. I would want for each disabled person the opportunity that I had: to prove myself worthy, to be given the chance to measure up to the standards that others had to meet, and on meeting those standards, to be allowed to participate in life and society in the most fulfilling way possible. For me, this has meant being able to become a doctor. I do not advocate the wholesale scrapping of standards to provide accommodation; however, the contribution of those standards to the process as a whole should be evaluated. I would not ask for accommodation so that I could be given training in, for example, piano tuning. Although this may be a possible achievement, it would be neither a prudent investment nor the best for people wanting their pianos tuned. Does every doctor have to be able to hear their patients to treat illnesses effectively? In my case, apparently not. But if I had to pay for the cost of accommodations myself, I may never have been able to complete my training. Let people with disabilities figure out what they can do. Give them the chance to be pioneers, to guide their own futures. The UCLA medical school saw enough potential in me to give me that first chance, and Oregon Health Sciences University has built on that by accepting me into their residency program. I am eternally grateful to both institutions. As a deaf woman, I am so thankful for the opportunities afforded me. I am aware of the sacrifice that others made that contributed to my success. If tomorrow someone offered me the ability to hear perfectly, but in exchange for my career, I would never accept. I am humbled and honored to be able to give of myself. In the words of Dag Hammarskjold, I am finding “the humility that comes from others having faith in you.”