Barriers Block Disabled Patients From Specialty Care, Study Finds

If you’re disabled and in a wheelchair, gaining full access to basic medical care can still be elusive, a new report finds.

The study, published online in the journal Annals of Internal Medicine, focuses on speciality care and concludes that even in our high-tech environment, something that seems fairly low-tech — getting a patient on to an exam table — doesn’t happen in many doctor’s offices. “Many sub-specialists could not accommodate a patient with mobility impairment because they could not transfer the patient to an examination table,” the report states.

It’s widely known — and a huge problem — that adults who use wheelchairs often face difficulties getting a complete physical examination because they have trouble getting on the exam table, says Dr. Lisa I. Iezzoni, director of the Mongan Institute for Health Policy at Massachusetts General Hospital. (Iezzoni, who has used a wheelchair for nearly 25 years because of multiple sclerosis, recently authored a report that found people with disabilities face major obstacles accessing a range of health services, from cancer screening to various medical treatments.) As a result, the study authors note, this patient population receives “less preventive care than their able-bodied counterparts.”

Dr. Tara Lagu, an internist at Baystate Medical Center

Dr. Tara Lagu, an internist at Baystate Medical Center

To investigate the problem further, researchers led by Dr. Tara Lagu, an internist at Baystate Medical Center in Springfield, enlisted medical students and residents to make appointments for a fictional obese (219 pounds), wheelchair-using patient with a recent stroke. They called doctors in four states (Massachusetts, Georgia, Oregon and Texas) and included a range of specialists — endocrinologists, gynecologists, orthopedic surgeons, ophthalmologists and psychiatrists, among others.

“We wanted a real-life snapshot of accessibility,” Lagu said. The callers would say: “I’m an internal medical resident trying to make an appointment for my patient — they had a specific script they had to adhere to.”

Shockingly, many of the office staff flat out refused to make an appointment, the researchers report. When asked why, some of these office staffers were quite direct and said it was not possible to get the disabled person on to the exam table.

You can listen to Lagu discuss the research here. But the bottom line (from the abstract) is this:

Of 256 practices, 56 (22%) reported that they could not accommodate the patient, 9 (4%) reported that the building was inaccessible, 47 (18%) reported inability to transfer a patient from a wheelchair to an examination table, and 22 (9%) reported use of height-adjustable tables or a lift for transfer. Gynecology was the subspecialty with the highest rate of inaccessible practices (44%).

Lagu said the study tracks with her “real life experience,” after 10 years as a doctor. “Pretty much everywhere I’ve been in my career, I’ve encountered this or a similar problem,” she said.

Lagu recounts the story of a friend from high school with spinal muscular atrophy. “She described that she was unable to get a pap smear because she couldn’t find a doctor with a lowering exam table.” And that’s in groovy, progressive San Francisco.

So, it wasn’t terribly surprising that in her study gynecologists seemed to have the highest rate of inaccessible practices.

“You cannot fake a pelvic exam,” Lagu said. “You have to put a person on the table, in stirrups. It’s the nature of the gynecological exam that creates a problem. It’s not about gynecologists as people,”

Iezzoni, who wrote an accompanying commentary, said the most startling aspect of the study was that “office staff seemed perfectly happy to say ‘We can’t accomodate them because they’re in a wheelchair.’ Their willingness to just speak openly about this suggests that they didn’t fully appreciate that what they were saying was illegal,” and in violation of the Americans With Disabilities Act. (The ADA of 1990 says all medical practices must provide “full and equal access to their health care services and facilities.”)

“You can’t really say it’s the doctor who is refusing to see the patient,” Iezzoni said. “But clearly the practices are not teaching the staff that they need to accommodate people with disabilities.” (She notes that adjustable exam tables that lower close to the ground so that patients can more easily move onto them from a wheelchair have been around for years. And though they are more expensive then regular exam tables, they are safer for everyone involved and avoid the need for office staff to lift people.) “That practices would decline to see patients with disabilities raises troubling questions about their commitment to a core tenet of professionalism: increasing access and reducing barriers to equitable health care,” she writes in her editorial.

Lagu adds that one of the problems with the ADA is that while it says medical practices have to be accessible, it doesn’t define what that means. Under the national Affordable Care Act there are new provisions that offer more detail and standards on specifically what type of equipment should be in doctors offices. “We hope this will make it more clear what it means to be accessible,” Lagu said.

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  • missioli

    It seems the 21st century hasn’t brought much efficiency to the delivery of health care for the disabled in this country.

    3 years ago I cared for a totally bedridden family member. To replace a feeding tube, the patient had to be conveyed by ambulance to a community hospital outpatient clinic. While there, I asked that the patient’s tracheostomy tube be replaced. That procedure was declined by the hospital. For that procedure, the patient would have to make a separate appointment for the pulmonologist’s office and then travel there by ambulance . The pulmonologist did trach changes at the hospital only for inpatients, not for outpatients !!!

    The cost to Medicare of a separate ambulance transport and the great stress and inconvenience to both patient and family was not a medical consideration.

  • star1234

    I have bad knees and cannot get on that one-foot-tall step to get on the table, either. I just sit in the visitor chair. As for gyno, I am over 65 and don’t get those anymore. I think doctors may figure you are disabled, so you must have some other doctor and just let it go.

  • Rick Gulla

    The researchers have done a great service with this study, pointing out that access to care can be difficult for some patients with disabilities. However, most of the reports on this study fail to highlight as Massachusetts Medical Society President Richard Aghababian, M.D. did in the report published in The Boston Globe, that the majority of practices did accommodate the patient requests in this study. Yes, it is important that physicians become familiar with the requirements of the American with Disabilities Act, and that they attempt to provide care for their patients. And yes I am writing from the physicians perspective, but the headline on this story, and the one in the Globe and those elsewhere, could just easily have read “Most physicians provide care for disabled patients.”

    The question has to be asked: Just where does one draw the line between “many” and “some” in reporting? Rick Gulla, Massachusetts Medical Society