Learning disabilities, professionalism, and the practice of medical education.

The authors use the interface of learning disabilities (LDs) and medical education to explore several issues relevant to medical professionalism and the training of future physicians. First, they examine arguments given by Little (in the preceding article) that a successful suit for accommodations on a state bar exam is generalizable to LDs and medical education, and suggest ways in which this may not be true. They then explore two frameworks for understanding medical education: (1) as a process of academic achievement linked to degree attainment, and (2) as a process of professional acculturation linked to competencies. Within this dichotomy, they then explore (1) the legitimacy accorded to different types of accommodations, (2) differing meanings of a "level playing field," and (3) the legal standard of "otherwise able." They also examine the use of intermediaries (e.g., a reader) as a "leveling" strategy and how, in clinical settings, this might violate core standards of autonomous decision making. The authors investigate the nature of "technical standards" in training across medicine and nursing and find a number of differences, particularly in the intent and levels of detail of standards. Across these two domains, they observe a status hierarchy, medical hubris, and the emergence of a "right to fail" as one travels down that hierarchy. The authors also examine medicine as an undifferentiated degree and consider arguments that medical school course requirements should be unbundled. They close by insisting that medical schools have a social responsibility to shift their pedagogic gaze from identifying handicaps in individuals to understanding how the education of physicians can become, quite literally, "handicapping."