Quad Doctors: In or Out?

By Aaron Broverman and Kent Cadogan Loftsgard

Dr. Sam Simms

“During an emergency, I am able to survey the whole room and will catch things most doctors would miss in the heat of the moment. It’s a luxury that I never had before.” — Dr. Sam Simms

In August 1999, while driving to work after closing the deal on a new house, 34-year-old Sam Simms was hit by another driver and crashed in a rollover accident. Unable to move, having difficulty breathing, and hanging upside-down in his truck, he knew he was paralyzed. As the medical director of the emergency department at St. Mary’s Health Center in Jefferson City, Mo., he’d been a doctor more than long enough to realize the gravity of the moment. “The ambulance crew said I was directing care and they’re like, ‘Dr. Simms, you’re the patient now.’ I guess your instincts kick in and you think you should be running the show.”

After counting every crack in the ceiling at the rehab center and seriously considering suicide, he started to slowly believe he really could go back to actually running the show. Dr. Simms recalls the reaction of interim ER director Dr. Larry Slaughter on learning of his hopes to return to a prior clinical role in the heart of the ER, instead of to his most recent administrative position: “I think he thought I was unrealistic in thinking there was such a thing as a quadriplegic emergency doctor.” Indeed, in a profile broadcast in May 2006, Missouri’s KOMU-TV speculated that Simms may be the world’s only quadriplegic ER physician.

If Simms’ colleagues are aware that other doctors with disabilities do exist, it’s no thanks to the Association of American Medical Colleges. While boasting about statistics on race, ethnicity and gender, the AAMC cites privacy and disclosure concerns to explain its failure to track medical students with disabilities.

The United Kingdom, however, does track med students with disabilities. In an academic paper published in May 2009 (“Doctors with Disabilities: licensed to practise?”), Dr. David Snashall, clinical director of Occupational Health at the UK’s St. Thomas Hospital, cites figures gathered by the University, Colleges and Admissions Service between 2000-2005: “Only about 2 percent of those accepted for medical training declared a disability or chronic illness compared to a figure of about 6 percent for students in general.” The same paper later cites U.S. and Canadian rates of acquired disabilities among working doctors, like Simms, at 2-5 percent.

As these figures demonstrate, Sam Simms belongs to a very exclusive club. Despite the ADA’s “reasonable accommodation” laws, supplemented by recommendations from the Association of Academic Physiatrists, and from a former chairman of the American Board of Medical Specialties, the U.S. medical system still presents too many barriers that keep capable doctors with physical disabilities out of medicine.

How Simms Stayed in the Game
Back when Simms first looked into returning to work, there was no precedent for what he wanted to do. How did this C6-7 quad convince the hospital and his malpractice carrier to grant him the seemingly impossible?

“The majority of what I did as a physician was cognitive, and I felt like my thinking was as clear as it ever was. I still had feeling in my hands, and the only thing I really couldn’t do was fine dexterity skills like sewing. Physician’s assistants, nurse practitioners and flight nurses do that all the time. I thought if I could just have an assistant, doing those things that are already done on a routine basis, there’s no reason I couldn’t [come back.]”

Neither the hospital nor his malpractice carrier found fault in his argument, and both agreed to a six-month probationary period — on the condition that he always have a backup doctor present. It worked so well that he has practiced the same way for 10 years. When a trauma patient first arrives in the ER, the stretcher is lowered to within Simms’ reach. He will typically work on the lower body, while his PA, or the other doctors on the case, will perform upper-body procedures.

“During an emergency, I am able to survey the whole room and will catch things most doctors would miss in the heat of the moment. It’s a luxury that I never had before.”

Simms’ wife of 26 years, Karen, has served as his physician assistant since early 2008. Thanks to her, he feels like he can be in two places at once. She stitches wounds and prepares patients’ paperwork while he talks to paramedics, interviews the family and consults with specialists to plan the best course of treatment. Many of his patients don’t seem to mind at all. “We’ll get former patients coming back for something else and they’ll say, ‘Dr. Simms, remember me? You sewed up my leg.’ My wife will tease me that they don’t even acknowledge her.”

Even Robbie, Simms’ service dog since 2004, plays a role in this medical care family by often comforting pediatric patients.

Humble about his popularity, Simms says it comes down to how patients relate to him: “Part of it may be empathetic, since they realize I’ve been in their situation. I come in at their level, so they’re not intimidated and they feel comfortable.”

He has become so much in-demand that his colleagues are now reluctant to let him reduce his shifts. However, Slaughter admits that Simms’ experience sets an example that can’t be emulated by aspiring medical students with pre-existing disabilities. “I think it would have been more difficult for Sam to get privileges if he didn’t have the prior history with the hospital,” he says. “I think he would have still gotten privileges, but he might have had more restrictions until he could show he could handle the work.”

What About New Docs with Disabilities?
For those not fortunate enough to be a doctor before being injured, the road to becoming a physician is nearly non-existent.

In early 1995, when New Mobility first spoke to med school student Jim Post following his well-publicized campaign to find an open-minded scholastic home, the 23-year-old quadriplegic was two years closer to becoming a doctor after landing at New York’s Albert Einstein College of Medicine in 1993. At that time Post praised Einstein’s accommodating ways: “I’m very much accepted here. The faculty is wonderful, the school is accessible, my grades are great, and I’m looking forward to going on the wards and doing the clinical part of my education. I can’t say strongly enough how much I love this school.”
Permitted to use a PA during his education, Post was later appointed chief resident and graduated in the top five percent of his class in 1997. Now 38, he’s been a nephrologist at New York’s James J. Peters VA Medical Center ever since.

Einstein welcomed Jim Post with open arms in 1993, but if he were an aspiring med student today, it’s likely he wouldn’t get in. Under the school’s current guidelines, physician assistants are not granted the right to “reasonable accommodation” in meeting technical standards:

“Under the law, a school need not approve any proposed ‘accommodation’ that may compromise patient health or safety. On this basis, ‘reasonable’ accommodations, which might be widely accepted in other types of educational programs, may not be approved by Einstein. … The dependence of patients on the skills and capacities of medical trainees and practitioners warrants that medical training institutions interpret and apply the Rehabilitation Act and the ADA differently than might other educational institutions, so Einstein technical standards do not allow for the ongoing use of intermediaries in the pursuit of a medical education at our institution.”

Einstein’s current motor-tactile technical standards include the following:

“Perform CPR; administer intravenous medication; apply pressure so as to stop bleeding; clear obstructed airways; suture simple wounds; and perform basic obstetric maneuvers.”

The guidelines also make clear that “Such actions require sufficient strength and effective coordination of both gross and fine muscular movements, equilibrium, and functional use of the senses of touch and vision.”

So why has Einstein now effectively barred its doors to all students with significant physical disabilities?

The Path to Licensing: Steeper and Steeper
Einstein neurology professor Herbert Schaumburg, a polio survivor and longtime advocate for Jim Post and other med students with disabilities, laments that all American medical schools — including Einstein — are at the mercy of the evolving regulations stipulated by the United States Medical Licensing Examination. “Einstein is in the same boat as every other medical school, and we have no choice but to accept the technical standards as they are part of the package that allows certification of the school’s ability to give the students access to the licensing examinations,” says Schaumburg. “Jimmy Post and I would be denied admission under these standards.”

Post and Schaumburg have sought legal counsel, and plan to challenge these new restrictions once an exemplary candidate with a suitable disability that can be used as a test case presents himself/herself for admission.

In its June 2005 publication, Medical Students with Disabilities: A Generation of Practice, the AAMC provides analysis of the ADA’s “Reasonable Accommodation” requirements:

“Courts have held several categories of requested accommodations as not required under the ADA or Section 504 [of the Rehabilitation Act of 1973.] Schools are not required to waive or eliminate an element, goal or purpose of a program in order to accommodate students with disabilities. Schools need not create new or different programs or services for students with disabilities or offer different or lesser benefits or services to students with disabilities. In addition, schools are not required to make reasonable accommodations where doing so would create a direct health or safety risk to the student or to others.”

The publication also cites legal findings which seem to support the USMLE’s current policies:

“The leading case in the education context addressing what constitutes a ‘fundamental alteration’ is Southeastern Community College v. Davis. In Davis, the Supreme Court held that a nursing school did not discriminate against an applicant with a hearing impairment by refusing to admit the applicant to its program. The Court held that the applicant was not otherwise qualified for the nursing program because, if the applicant were to participate in the clinical phase of the program, the applicant would have to be provided with an individual nursing instructor in order to ensure patient safety. The Court concluded that if the applicant were unable to participate in clinical courses without close supervision, the nursing school could only allow her to take academic courses, a situation that would not equate with the degree of training a nursing school normally provides. The Court held that such a fundamental alteration in the nature of a program is far more than the ‘modification’ required by Section 504.”

The current version of the USMLE’s Guidelines To Request Test Accommodations, published in July 2007, lists specific sections addressing learning disorders, attention deficit hyperactivity disorder, or vision impairments. Noticeably absent is any clear acknowledgement of hearing impairments or mobility limitations; noticeably present are allowances made for those with cognitive disabilities.

Dr. Joel DeLisa, former chairman of the American Board of Medical Specialties, decries this double standard. He asserts that medical students — especially residents — with cognitive disabilities pose a greater overall potential threat to public health and safety: “All sorts of these games get played. Mental and other disabilities are hidden, so they get through that screen, while those with physical disabilities are barred.”

As for medical schools’ responsibility to society, DeLisa says that “protecting the health and safety of their patients” by prohibiting qualified candidates with physical disabilities while still admitting those with cognitive or invisible disabilities, “is just another excuse.”

An Association of American Medical Colleges admissions department employee, who requested anonymity, confessed his suspicion that many students with mental disabilities or other invisible deficits have, “snuck through.”

If, as the Davis case suggests, medical training institutions may legally argue that those who require an “intermediary” fail to meet the fundamental definition of a qualified medical practitioner, and if those with potentially more dangerous unseen ailments continue to “sneak through,” where does this leave America’s next generation of doctors with physical disabilities?

Simms had the support of his colleagues, who banded together to relieve the cost of his physician’s assistant, but Post reasoned that paying for his own assistant was more acceptable than the risk of losing his academic dream by complaining.

It’s hard to deny that doctors who have personally experienced disability are far more likely to be sensitive to the needs and emotions of their patients, but the regulatory restrictions imposed since Post’s school days have made an already uphill battle even steeper.

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