Existing healthcare disparities have been unmasked and exacerbated during the COVID-19 pandemic, which has also emphasized for many the benefits of retaining diverse clinicians [15]. In accordance, our study describes an under-recognized segment of the healthcare workforce: deaf and hard of hearing individuals and their experiences applying to and during health professional schools and training with accommodations. Building on a previous study of medical students and physicians [32], this study broadens the scope of inquiry to the larger DHH workforce by including other healthcare professionals, with nursing professionals representing about one-fourth of our respondents and physicians one-third. Interestingly, audiologists represented the third largest group, consistent with our anecdotal observations of DHH people becoming increasingly interested in hearing health. Respondents were mostly white, female, comfortable with English, with a severe to profound hearing loss. They varied by self-identification as well as comfort with signed communication, and included representation from minoritized groups (such as those who were LGBTQ, or immigrants or children of immigrants), reflecting diversity within the community of those with a hearing loss.
Most respondents were admitted to a health professions program, accepted into post-graduate training, and went on to full employment. While this trend is cautiously promising, more than one in ten respondents reported not being accepted to school or gaining employment, which we suspect is an underestimate since people who were not accepted may have exited the health professions, thus being less likely to be recruited into our survey, or may be reluctant to report this information. Importantly, accommodation satisfaction was associated with gaining employment for those moving directly from school to employment. It may be that students who are appropriately accommodated have more success and confidence in their abilities and as a result are better equipped to engage in accommodation-related discussions while seeking employment; there is also the possibility that more effective accommodations improve the quality of education and training, with subsequent positive effects on candidacy for successful entry into the workforce. Despite our findings of success, work remains to optimize DHH students’ capacity to successfully apply to healthcare professional schools.
Consistent with previous findings, there was wide variation in accommodation need, satisfaction, and utilization of accommodations, and in engagement with a DRP, affirming that DHH people cannot be addressed as a uniform population [37]. Only about half of participants reported satisfaction with accommodations, suggesting that some accommodations may not meet the needs of individuals who are DHH in school or postgraduate training. Additionally, accommodation use may be a burden for some students. For example, while in school, participants invested a mean of 2 personal hours weekly to manage their accommodations (range 0–30 h), raising concerns that DHH students may be burdened with additional administrative duties beyond the already taxing role of navigating professional studies. Notably, our finding parallels those from a study conducted nearly a decade ago, in which respondents reported a mean weekly time investment of 1.3 h [32]. New to this study was the inquiry about the use of a DRP to assist with the accommodations process. Approximately half of respondents reported working with a DRP in school. The use of a DRP to assist with accommodation management dwindled in post graduate education and into employment. The lack of a specialized DRP who understands the health professions environment is a noted barrier to success in the AAMC report on disability in medicine [21]. It may be that the lack of specialization in accommodations in clinical settings, and subsequent mismatch between accommodation need and approved accommodations, is driving the lack of statistical association between DRP use and accommodation experience as identified in our analyses.
Most participants reported an intention to work or are currently working in primary or generalist care (including nurses, pharmacists, and other HCP in addition to physicians, also reflected in specialty choices within professions as reported in Table 5), a lower percentage than reported in the previous study [32]. This difference may be reflective of the smaller number of physician participants in this study, compared to previous investigations focusing solely on physicians. Despite this decline, our findings support recent scholarship on the association between students with sensory/physical disabilities and match to primary care [19].
To our knowledge, no data exist on the number of physicians who serve the DHH population; however, respondents here report that approximately one third of their patients are, or will be, DHH. This estimate is double that of the general population of patients who are DHH (15%) [38], suggesting that DHH health care providers may fill an unmet need for patient communication concordance in the broader DHH population. Previous studies suggest that clinician-patient race and language concordance have the potential to reduce barriers in access to care, improve patient care and adherence, and reduce healthcare disparities [37, 39]. It is possible that these same benefits could occur in DHH physician-patient concordant care. This study did not address whether clinicians and students who are DHH have an interest in working with other minoritized patient populations, though this question should be explored in future work.
Another concern warranting further exploration is the potential current risk for depression among some respondents. In the 2013 study only 2 participants screened as at-risk for depression, while the current study identified 17 participants at risk; though this was not specific to one particular profession. Interestingly, we found a small and statistically significant association between positive depression screening and lower accommodation satisfaction for those in school, a finding that has not been explored thus far in the literature to our knowledge. While our analyses were not designed to investigate causality, it is feasible that dissatisfaction with accommodations or the need to invest significant time in their management could contribute to concerns about the risk of depression.
Taken together, these findings implore healthcare educational institutions to provide focused support for healthcare professional students with disabilities in the form of disability resource expertise, evaluation of accommodation efficacy informed by the learner, and a devoted disability resource professional to facilitate accommodations, relieving students of that duty and allowing them to devote their time to education and training as future healthcare practitioners. By providing high-quality effective accommodations, specific to the learner, healthcare professional programs can enhance the educational pathway to a diverse workforce by recruiting, supporting, and graduating learners with disabilities. Recommendations to this end have already been published for medical schools’ technical standards and residency programs’ disability policies, yet are disproportionately implemented [24,25,26,27,28,29]. Additionally, in describing the DHH workforce, and their use of accommodations, preclinical students that are DHH may realize a pathway to health professions that has not been well described or investigated.
These results must be interpreted in light of their limitations. As an online survey delivered among professional networks, self-selection and decisions not to respond to all questions impact our ability to generalize each response to the full population of DHH people in healthcare. Sampling bias may also account for the high proportion of female respondents. As previously noted, we do not yet have longitudinal data from a nationally representative set describing healthcare professionals who are DHH, especially since many acquire a disability later in life after attaining employment; we cannot extrapolate from our results to those with late-onset hearing loss. Those in school or practice were possibly more likely to answer, and our results cannot adequately describe those who were not accepted. The small number of respondents who were in or completed residency or fellowship challenges our ability to describe that career stage within our results. Our methodology precludes incorporation of perspectives from education administrators or employers on accommodations. Similarly, we are unable to verify participants’ reports on their work with patients who are DHH, examine the impact of concordance of communication or deafness on patient care, or describe patients’ or non-DHH professional colleagues’ perspectives on such concordant care.
Our findings support and build on previous results. Further research, including qualitative approaches, is needed to explore the drivers of success for people who are DHH, including accommodations, the types and utilization of DRPs, education quality, and wellness, as educational experiences prior to healthcare professional school. This work should consider the intersectional experiences of people with disabilities [40]. It is also essential that school networks and accrediting organizations add disability items to their demographic collection systems so that DHH people can be identified and described more rigorously beyond our sampling methodology. The AAMC has already added disability items to their second-year and graduating medical student questionnaires.