Q&A: What are physicians’ legal obligations under the Americans with Disabilities Act?
The results of a new survey suggest that many physicians do not completely understand what the Americans with Disabilities Act means for them.
Lisa I. Iezzoni, MD, MSc, a professor of medicine at Harvard Medical School, and colleagues surveyed 714 U.S. physicians who worked in outpatient settings about their knowledge of the Americans with Disabilities Act (ADA), a 1990 law that legally requires reasonable accommodations for people with a disability.
Among the survey respondents, 62% were men; 64.5% were white; 61.7% worked in private, community-based practices; 66.5% had been out of medical school for more than 20 years; and 36.2% either had a significant disability or had a family member with a significant disability. Most of the survey respondents were internists or family physicians. Others included rheumatologists, neurologists, ophthalmologists, orthopedic surgeons and OB/GYNs.
According to the researchers:
- 71.2% of participants did not know who determines reasonable accommodations under the ADA;
- 68.4% felt that they were at risk for ADA lawsuits;
- 35.8% said they knew “little or nothing” about their legal responsibilities under the ADA; and
- 20.5% did not know who pays for accommodations that would make their practices ADA compliant.
The findings build on previous survey data from the same group of respondents. In that survey, Iezzoni and colleagues asked participants about their perceptions of patients with disabilities. Only about 40% of them said they were very confident in their ability to provide the same quality of care to their patients with a disability as those without disabilities. In addition, just 56.5% strongly agreed with the statement that they welcome patients with disabilities into their practice and 82% reported that people with significant disability have worse quality of life than nondisabled people.
“Putting together these two pieces of data, it raises a concern that we need to better understand what’s going on among our patients with disabilities,” said Iezzoni, who is also a professor at the Health Policy Research Center at Massachusetts General Hospital.
Healio asked Iezzoni to discuss the legal responsibilities of physicians under the ADA, how physicians can improve care for patients with disabilities and more.
Healio: What are physicians’ legal responsibilities under the ADA?
Iezzoni: Physicians need to accommodate their patients with disabilities to ensure the patient gets equitable care and is effectively communicated with.
The ADA does not specify exactly what should be done for each patient, since the act assumes every individual has their own specific needs. In other words, it sets out basic principles, but then the ways those principles are attained is very specific to the context and what the individual patient’s needs are.
For example, I am a wheelchair user with multiple sclerosis. Although I still have enough strength in my legs that I can stand very briefly and pivot to sit on an exam table if I need to, somebody with a spinal cord injury may not be able to put weight on their legs. We would need different types of accommodations to get us on to the exam table. The ADA is not a cookie cutter. Physicians have to talk to their patients to figure out what will work best.
Healio: How can physicians help patients with disabilities feel a greater sense of freedom and independence?
Iezzoni: That is a terrific question.
Physicians can have office equipment that allows the patient to do as much for themselves as possible. For example, there are exam tables and electronic devices that with the push of a pedal go up and down.
Section 4203 of the Affordable Care Act required the federal government to come up with standards for accessibility of medical diagnostic equipment, including exam tables, weight scales, mammography machines, gurneys and diagnostic imaging equipment. However, Jeff Sessions, while an attorney general during the administration of former President Donald J. Trump, announced that they were not going to do scoping rules that specified how widely available that accessible equipment for patients with disabilities needs to be.
Healio: Who is responsible for paying for upgrades that make facilities compliant with the ADA?
Iezzoni: The ADA covers structures, parking lots and sidewalks, but it does not cover the contents of the structure or its furnishings. It does not cover the cost of things like the adjustable exam table we talked about earlier, but the federal government does offer tax credits to improve accessibility under the ADA.
While it is true that automatically adjustable exam tables are slightly more expensive, physicians need to balance that increased cost against things such as staff injuries that could occur when lifting patients onto an examination table that is not adjustable. Nurses and physician assistants are the second highest group of workers with occupational injuries. If a physician can prevent staff injuries by having equipment that does not require lifting and moving patients, that’s a win-win. Height adjustable examination tables are also ergonomically best for the physician, so that is another win-win. The cost issue of making physicians’ offices ADA-compliant needs to be balanced out against what the savings might be from some of these other concerns.
Healio: When do primary care physicians need to worry about ADA lawsuits?
Iezzoni: One of the most common lawsuits stems from lack of communication accommodations for patients who are deaf. Some physicians will offer to write notes back and forth, and some physicians will not offer any kind of assistance at all.
Physicians who refuse to provide American Sign Language interpreters for office visits may find themselves in problematic situations. For example, a focus group conducted among people who are deaf once found out about a man who described the doctor writing on a note to him, “Do you use coke?” The patient wrote back, “Yeah, I really love it.” The patient was immediately required to provide a urine specimen sample, although further investigation revealed it was not needed. The doctor was referring to cocaine, the patient was referring to the beverage.
In another example, a woman was told by her doctor an American Sign Language interpreter was not needed to explain what a Pap smear was because she was young and it was a routine exam. The subsequent experience was so terrifying for her that she said she was never going to go back for another Pap smear. Think about that in the context of how preventable cervical cancer is.
Healio: What kind of education programs do you think are needed to improve physicians’ knowledge of the ADA?
Iezzoni: That is a really great question.
People always say, well, we should teach this in medical school, and I agree. But it takes 7 years to train a doctor, and right now, 25% of Americans have disabilities. Therefore, we also need to talk about the ADA at professional meetings and in continuing medical education.
Healio: Is there anything you would like to add?
Iezzoni: The findings of our papers really make you wonder if some physicians are deciding to not conduct routine screening tasks like peptides or maybe not communicating as well with people with disability because they do not respect their lives.