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Alan Weil interviews University of Michigan's Lisa Meeks on her recent paper she and colleagues published exploring the topic of mistreatment of physicians with disabilities.
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;24;11
Alan Weil
Hello and welcome to A Health Podyssey. I'm your host, Alan Weil. When we talk about disability and health, which is the topic of the entire October 2022 issue of Health Affairs, we usually focus on the experiences of people with disabilities, navigating the health care system. We examine their health status or their access to care. But this misses an important dimension.
00;00;24;19 - 00;00;48;25
Alan Weil
The role of clinicians with disabilities in the health care system. Now, by one estimate, 3% of physicians in the United States have a disability, although most observers believe this is an undercount. Having people with disabilities in the physician workforce is essential for many reasons. Not only are physicians with disabilities more likely to understand and be able to meet the needs of patients with disabilities.
00;00;49;07 - 00;01;22;11
Alan Weil
But having people with disabilities in the health care workforce is an important part of inclusion representation, and even compliance with anti-discrimination laws. So how do physicians with disabilities fare in the workplace? That is the topic of today's episode of A Health Podyssey. I'm here with Lisa Meeks, assistant professor of Learning Health Sciences at Michigan Medicine. Dr. Meeks and coauthors published a paper in the October 2022 issue of Health Affairs exploring the topic of mistreatment of physicians with disabilities.
00;01;23;01 - 00;01;42;19
Alan Weil
Their findings are really quite disturbing. Physicians with disabilities experience high rates of mistreatment from both their coworkers and their patients, and they're much more likely to experience this mistreatment than physicians without disabilities. We'll discuss these findings in today's episode. Dr. Meeks, welcome to the program.
00;01;43;25 - 00;01;56;05
Lisa M. Meeks
Thank you, Alan, and thank you for having me today. I also want to just thank Health Affairs for this issue and for the commitment to bringing this work to the forefront and front of mind for policymakers.
00;01;56;15 - 00;02;16;15
Alan Weil
Well, thank you for those comments. And we're really happy and proud of the effort here. Of course, the test will be whether things change, because we've sure documented a lot of challenges and problems. And unfortunately, you've done that, too, in your paper. But I appreciate the kind words, and we're hopeful that it will lead us to a better place.
00;02;17;12 - 00;02;40;18
Alan Weil
Your paper focuses on a specific topic about mistreatment, but you know, a lot about this field. And before we go into the details of the paper that we published, I wonder if you could just say a little bit about the general picture of medical education for students with disabilities. Why do we see such a small share of the physician workforce composed of people with disabilities?
00;02;40;19 - 00;02;44;24
Alan Weil
I know there are lots of reasons, but I'd love to get your opening thoughts on that question.
00;02;45;24 - 00;03;09;20
Lisa M. Meeks
Yeah, thank you for the question. I think first I want to note that this work, the collective work, is really a team effort from many, many colleagues and partners. One, the internal health study at Michigan, and then the other is the AAMC, who have been pretty incredible in partnering with us on developing questions, collecting data, and then looking at policy changes.
00;03;09;20 - 00;03;43;15
Lisa M. Meeks
And the work we're discussing today comes from that AAMC partnership from the Workforce Team led by Michael Dill. And, you know, we've been collecting data about this population since about 2014. And what that work tells us is that the prevalence of students in UME, so medical students is rising, and it's rising significantly year over year. And benchmark estimates of residents as well, or GME the next level of training, show a small decline from UME, but not significant.
00;03;43;28 - 00;04;18;13
Lisa M. Meeks
And fortunately, this work, our paper showing that 3% of physicians report disability is a significant and frightening decline. And so trying to figure out what's happening as learners, trainees go across that medical education continuum is the new focus of our work. And collectively, we and historically we've worked to identify specific pinch points in the educational pathway and there are many we could have this entire interview, could be about those barriers.
00;04;19;10 - 00;04;58;09
Lisa M. Meeks
But I do find that the ableists ideas in medicine, a lack of understanding about disability or subscribing to disability tropes are really problematic and they also lead to a lack of infrastructure to support disabled learners and physicians. So if you think about it this way, if you have an idea of people with disabilities and what they're capable of and that idea is wrong, then you won't anticipate people with disabilities being in your training and educational spaces and therefore you wouldn't build in those supports or mechanisms for full access.
00;04;59;01 - 00;05;22;13
Lisa M. Meeks
But I do want to say that ableism is what we're taught as a society. I think everyone probably has a level of ableist belief, so we have to actively unlearn this and this takes time and practice. It also takes an awareness that this is your belief system, which is part of the work of your podcast, right? We're talking about it today and our docs with disabilities podcast as well.
00;05;22;23 - 00;05;31;05
Lisa M. Meeks
I think we have to do a lot of myth busting around disability and get rid of those assumptions and that ableist mindset.
00;05;31;05 - 00;05;51;15
Alan Weil
You cover a lot of ground there, but I do want to highlight one really important element of what you said. In equity work, there's often discussion of the metaphor of the pipeline that, you know, you get people in. And then if you want to have a more diverse end point to, you have to bring people in at the front end.
00;05;51;25 - 00;06;16;19
Alan Weil
And often the focus is on entry into the pipeline. And what you just described is a situation where I'm not going to say there aren't challenges with respect to entry into the pipeline, but what you're describing is a lot of loss along the way due to, as you say, systems that aren't designed to support people with disabilities. So even if we're successful in recruitment, bringing people in, we're losing them along the way.
00;06;16;19 - 00;06;39;27
Alan Weil
And that's both a good and a bad. On the one hand, it's great if you're doing better at the front end of the pipeline, it means you're finding folks and that's really great. But of course, if you're losing them, that's a huge problem. And we've got to talk about why. So let's turn to the paper here, which is one dimension, I understand, of what, as you said, we could talk about in many other ways as well.
00;06;40;06 - 00;07;01;28
Alan Weil
But this was a study focusing on mistreatment. Now, I do think when we talk about terms like this and survey data, it probably is particularly important for people to understand what that means. So if you can just say you focused on mistreatment, what are the types of mistreatment that were looked at, who's mistreating whom? And then we'll get into some of the findings.
00;07;02;21 - 00;07;37;08
Lisa M. Meeks
Sure. Well, in this paper, we looked specifically at offensive remarks. And so some of our questions were, were you ever subject to offensive sexist remarks, racially or ethnic offensive remarks, offensive remarks or names related to sexual orientation, offensive remarks or names related to disability and remarks based on your personal beliefs? But we also investigated harm, physical harm. So we looked at whether people were threatened with physical harm or if they actually experienced physical harm.
00;07;37;17 - 00;08;01;15
Lisa M. Meeks
And then finally, and not surprisingly, we also looked at being subject to unwanted sexual advances, which is something that a lot of people are investigating in medicine. And when we did this, we were looking at two sources of this mistreatment, one being patients, which again, has been done in multiple studies, not with disability, but across lots of other groups.
00;08;01;28 - 00;08;09;21
Lisa M. Meeks
But we also looked at peers, and this is where I think the most surprising information came from.
00;08;09;21 - 00;08;33;22
Alan Weil
Okay, so you're getting us excited about hearing the results. I know all of the findings are in the paper and I'd encourage our listeners to go there. But why don't you, if you could say a little bit about the what I call the top level findings, rates of mistreatment of the types you described, and then the ratio, the odds ratio, how much more likely people with disabilities were to experience this than people without disabilities?
00;08;34;09 - 00;09;12;08
Lisa M. Meeks
Yeah. And, you know, exciting is one word. When we found the data and we met as a team, it was a somber meeting because while the findings were startling, they also unveiled this absolute environment where people were subject to a lot of mistreatment. So it was really difficult for our team as we were going through the data because again, as a research team, this was significant data, but it made us extraordinarily sad for physicians with disabilities who are experiencing this.
00;09;12;21 - 00;09;44;16
Lisa M. Meeks
And what we found was that physical harm was the most shocking. I think, although it is rare for people to report physical harm, 24.6% of our physicians of physicians with disabilities experienced this from their coworkers. Now, this is compared to only 1.8% of physicians without disabilities. And then again, another 26 or so percent of physicians with disabilities experienced physical harm from patients.
00;09;44;28 - 00;10;30;23
Lisa M. Meeks
Now that is compared to only 5.3% of physical harm from their non-disabled peers experience from patients. So pretty significant findings there. And to put this in a kind of a different perspective, disabled physicians were 6.5 times more likely than non-disabled physicians to be harmed by patients and 17 times more likely to be harmed by their coworkers. We know that violence towards physicians is rising, so this heightened physical harm towards physicians with disabilities was really quite startling and something we feel needs to be monitored and addressed.
00;10;31;06 - 00;10;54;15
Alan Weil
It is a horrible picture and we start with data so that we have a sense of the scale of the problem and then we'll turn to sort of what to do about it before we go on, I do want to bring in the other types of mistreatment, the verbal and not, you know, the not physical, because those were striking as well.
00;10;54;15 - 00;11;03;19
Alan Weil
Maybe not as surprising to you, but they were surprising to me. Can you say a little bit about the incidents of the types of verbal mistreatment?
00;11;04;07 - 00;11;38;10
Lisa M. Meeks
Yeah. So you know, when we looked at what we saw, the least of it was by patients and it was racially or ethnically offensive remarks. And then what we actually witnessed was the highest, which I think is what we had anticipated to find. And in what the listener probably is estimating that we found as well, which was offensive remarks are names that are related to a person's disability, but very close to that was also offensive remarks are names related to sexual orientation.
00;11;38;10 - 00;12;06;08
Lisa M. Meeks
And something interesting about our data here was that we had overrepresentation of individuals that identified as non-heterosexual. We actually find that same interesting finding in a lot of our datasets. So, you know, these individuals at the intersection of sexual identity and disability are probably even more likely to experience mistreatment in the environment.
00;12;06;29 - 00;12;47;24
Alan Weil
Well, these issues of intersectionality are central to the entire topic of disability. I want to explore that with you more and some of the other findings will have time to do that after we take a short break. And we're back, I'm speaking with Dr. Lisa Meeks about patient and coworker mistreatment of physicians with disabilities. Before the break, you introduced the topic of intersectionality, and you mentioned something that I think is exactly what came to my mind as I read this study.
00;12;47;24 - 00;13;17;29
Alan Weil
If you ask about mistreatment directly related to the physician's disability being called a derogatory term associated with your disability, that's a horrible thing. You would expect the rates of that for people with disabilities to be relatively high. You'd expect it for people without disabilities to be relatively low. What you might expect is up to the person's, you know, going in assumptions.
00;13;19;07 - 00;13;51;06
Alan Weil
But even that just the amount of sort of derogatory language about disability per say was in my mind strikingly high. So before we get to these other types of mistreatment or dimensions of mistreatment, I'm not sure what the exact right word is, I'd like to focus just on where you started about ableism, that what are we observing when we see this kind of language around disability that's done in a harmful way?
00;13;52;03 - 00;14;35;00
Lisa M. Meeks
You know, we often have derogatory use of language around disability in everyday social environments. So in the movies, in music, it's part of the fabric. This ableism is part of the fabric of society and it's how we're all raised. So I think one of the reasons that we see behavior that is more ableist in nature and we see higher levels of it is because we haven't kind of gut checked this as a society and we haven't done as much work on this as we have for other marginalized populations or minoritized population ones.
00;14;35;09 - 00;15;06;22
Lisa M. Meeks
So we've done a pretty good job of trying to educate people on why something is not appropriate to say or do. For example, with a underrepresented ethnic group or an LGBTQ population individual, something of that nature. But we really haven't done that around disability. And while we see, you know, kind of course correction in different areas, I think that as a whole we haven't done that as a society.
00;15;06;22 - 00;15;29;25
Lisa M. Meeks
And so I honestly and I choose to believe this because I'm an optimist. I honestly believe that many people don't even understand when they're doing something offensive when it comes to disability. And perhaps if we were able to peel back that layer and, we can't here because this is one big data set, where we don't know the specifics about what happened.
00;15;30;03 - 00;15;55;15
Lisa M. Meeks
But it could be that if we were to pull back those layers, we would find that people did not have an intention of being offensive or harmful when they made those remarks. And that's what I would hope that the optimist in me, I think hopes and so education, if you think about it from that perspective, education would be really valuable.
00;15;55;15 - 00;16;23;01
Lisa M. Meeks
And bystander intervention. So say a nurse or a respiratory therapist or physical therapist is in the space and overhears one of these comments being made. It shouldn't be just the person with the disability having to give that gentle feedback to the patient or to the peer. It should be a community of people who are saying, hey, you know, I know you may not understand this, but that remark may be offensive.
00;16;23;01 - 00;16;26;16
Lisa M. Meeks
And this is why, and doing a little bit of that education.
00;16;27;13 - 00;16;55;02
Alan Weil
It's very helpful. And I mean, I hope you're right that a lot of this is unintentional. And I certainly think you're right that as a society, we just haven't done nearly as much work on drawing attention to this sort of behavior. And education is a good starting place. So that's sort of the nicer part of the story, I suppose, if you will, or the solvable, potentially solvable if it really comes from social norms.
00;16;55;16 - 00;17;21;23
Alan Weil
But then we have these other findings and you started to allude to them earlier that there are types of mistreatment associated with other parts of a person with disabilities, identity that are much higher for people with disabilities and for people not with disabilities. I'm trying to get my head around that. Like what? Again, I sort of asked and I realize it's maybe a strange way to ask questions, like, what's going on here?
00;17;22;02 - 00;17;39;03
Alan Weil
When you see higher rates of mistreatment associated with gender identity for doctors with disabilities than doctors without disabilities, when the mistreatment isn't about the disability, it's about something else. What's going on there?
00;17;39;23 - 00;18;04;25
Lisa M. Meeks
It's a good question. And it's one that our team is also thinking about. And we were surprised. However, one of the things that concerns me is that and this is the less optimistic there is Alan, is that people may feel a sense of superiority and a right to comment on perceived attributes of a person with a disability.
00;18;04;25 - 00;18;31;19
Lisa M. Meeks
If they don't value individuals with disabilities then they feel that this group is less than. And so it's not dissimilar to what we might witness for other marginalized groups. And I think studies point to this a lot. There's a high prevalence of discrimination aimed at physicians of color, particularly black men and women, and also to the other groups that are also minorities.
00;18;31;19 - 00;19;02;29
Lisa M. Meeks
So based on the four groups that are based on their sex or gender or sexual orientation. And one of the things that we have to contextualize all of this with is that we've also, in the last few years witnessed, I believe, unfathomable acts of violence and oppression. This is also really exclusion against people of color, those in the LGBTQ community and people with disabilities.
00;19;02;29 - 00;19;24;24
Lisa M. Meeks
And, of course, all of this warrants action on our part. But I see a bigger connection between the isms, if you will, that these kind of systems of oppression are working together to keep one another down. So in some ways, it doesn't surprise me that you might get a comment based on the color of your skin or your sexual identity, if that's known.
00;19;25;07 - 00;19;58;26
Lisa M. Meeks
I think that these systems of oppression work together and the obstacles to improving the conditions is the lack of awareness that they are interrelated. No, ableism is a form of racism and heterosexism and ageism. And all these isms, I think, work together to deny all sorts of people access. So I think it's critical that when we see findings like this, we think about how we need to broaden the umbrella when we're talking about justice, equity, diversity and inclusion.
00;19;59;12 - 00;20;10;19
Lisa M. Meeks
And as we start to address these things like racism, that we also address ableism as part of that, and that these two things really can't be teased apart.
00;20;10;19 - 00;20;49;07
Alan Weil
Yeah. This is not the education story, is it? This is much more complex. And it does feel like when you talk about superiority and someone being less than the findings about unwanted sexual advances just support that hypothesis. So well that, you know, if someone is your object, then you're going to treat them like an object. And that's- the data show some level of objectification and all of these isms, as you say, they build upon each other.
00;20;49;07 - 00;21;17;11
Alan Weil
And so once someone is less than in one dimension, it's easier to treat them less than in another dimension. And what I'm struck by is that these data just show so clearly how those multiply together, because you wouldn't have differential rates of mistreatment on a racial dimension for people with disabilities if there wasn't some kind of a intersectionality, which is the term we use.
00;21;17;11 - 00;21;45;10
Alan Weil
So it's very disturbing. I don't believe in ending on negative notes. No one wants to go away unhappy. The findings really are disturbing. But again, you work in a space where you're also looking at solutions. You mentioned education as a potential way out, particularly for those areas where this may just be sort of lack of awareness. But how do we go beyond that?
00;21;45;10 - 00;22;02;17
Alan Weil
And what's the role of the community of medical educators in particular to improve the numbers and make this pipeline more secure and make the workplace more appropriate?
00;22;03;05 - 00;22;28;09
Lisa M. Meeks
Well, I think that there's a lot that institutions can do to address the concerns. And I think first and foremost and we saw this as a thread throughout all of the papers in Health Affairs. And I'd encourage everyone listening to, not just read our paper, but read all of the papers because it really is so impactful when you see it in context, in the kind of the totality of what's happening right across all of the different spaces.
00;22;28;09 - 00;22;50;15
Lisa M. Meeks
But one of the threads was to collect data and this is such an example here is that we would never know that there's this huge drop off in the physician workforce with regard to disability. If we weren't collecting data and we were able to see this pattern across the pathway, so first and foremost, collecting data and lots of it.
00;22;50;25 - 00;23;12;11
Lisa M. Meeks
This allows us to monitor the recruitment and retention of physicians in the workplace and to help identify those pinch points in the workplace, which we have not done yet. But this is really important to figure out where we flip the switch, where we have a potential attrition issue and what's happening right before that, so that we can fix it.
00;23;13;03 - 00;23;41;15
Lisa M. Meeks
I think it's important to, again, change that narrative to do a lot of myth busting and talk about the value of physicians with disabilities. Hospital systems and educational systems can easily do this by sharing stories about how physicians with disabilities are impacting and informing medicine across not only the United States, but really across the entire globe. And we need to conduct training.
00;23;41;15 - 00;24;06;05
Lisa M. Meeks
This is where the education part comes in. We need to make people aware of what ableism is. We need to call it out. We need to define it. We need to provide examples. People can't do their own kind of disruption of their biases if they're not aware that they exist. And then we need to increase efforts for inclusion.
00;24;06;05 - 00;24;44;05
Lisa M. Meeks
And that's both in the education space but also in the employment space. I get a lot of emails, Alan, where people say, what could we do to increase the numbers of people with disabilities in our environment? And not that, you know, I'm laughing because they're there already. These individuals are just afraid to identify as disabled and there are tons of people with disabilities who would love to be part of the health care workforce and would do a great job in forming the provision of health care not only for people with disabilities, but for patients writ large.
00;24;44;18 - 00;25;10;06
Lisa M. Meeks
And so making sure that we are promoting our welcoming of this population is critically important. Messaging is far more important than you can imagine. And then to what we were speaking about earlier, making sure that the support systems are in place, it's not enough to bring people in and say, look, we have seven or eight or 9% people with disabilities.
00;25;10;15 - 00;25;44;00
Lisa M. Meeks
You have to create an environment where that support is continued throughout the pathway and into employment. And then very specific to our findings, which again were just so disheartening, we need reporting systems for mistreatment and those reporting systems need to include disability as a root cause of mistreatment. Right now, most reporting systems don't have disability as part of the mistreatment, the only thing that people can do is file a complaint about discrimination.
00;25;44;00 - 00;26;12;24
Lisa M. Meeks
And if much of this mistreatment is coming from patients, patients come in and out of the space. So filing a complaint about discrimination takes a long time to investigate. We need actionable items from mistreatment from both populations, both patients, and from their peers. And the policies must have clear expectations for employees and patients specific to multiple elements of harassment.
00;26;12;24 - 00;26;50;01
Lisa M. Meeks
As we witnessed. This isn't just about remarks about somebody's disability, and much of this harassment can be overt and covert. So we must address it on both levels, and then there must be clear consequences. If there are no consequences or accountability, we're going to have a hard time getting people to comply with non-harassment policies. And although these are interventions and education I think are partially effective, they're not effective if they're not implemented in a culture of trust and accountability.
00;26;50;15 - 00;27;15;08
Lisa M. Meeks
And so many people we know from, I know from my work on sexual harassment, that many trainees and physicians do not disclose that they're being harassed, especially by a peer, because they believe that nothing will happen. And if you're working in a system where you believe that you are not valued and nothing will happen if someone is mistreating you, you're not going to say anything.
00;27;16;08 - 00;27;43;29
Lisa M. Meeks
So I think institutions can do a lot. But they need to do it in a culture of trust and accountability. They need to build this with their physicians and with their trainees and physicians and trainees need to believe and trust that if they report something, there will be an action and that if they report something, they will be protected against any sort of retaliation for that reporting.
00;27;44;14 - 00;28;15;22
Alan Weil
Well, I'm really glad I asked you about solutions, because education is an element. But you're right, it's much more than that. And trust, accountability, data, all of these are parts of what it's going to take to do better. Dr. Meeks, thank you for focusing on this topic in general and bringing your wisdom and insights about it. For this study in particular, which we're proud to publish, that does shine a really difficult light on an unpleasant but incredibly important topic.
00;28;16;03 - 00;28;19;04
Alan Weil
Thank you for being my guest today on A Health Podyssey.
00;28;19;13 - 00;28;28;29
Lisa M. Meeks
Thank you so much. And thanks again to Health Affairs for this entire issue and thanks to the whole team that brought this paper to life.
00;28;29;18 - 00;28;42;13
Alan Weil
Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about A Health Podyssey.