What’s Important: Equitable Orthopaedic Care for Patients with Disabilities

At a young age, I (U.B.) learned that health care is inaccessible to many patients. Walking arm-in-arm with my aunt, who is blind, into her doctor’s office allowed me to see early on that health care was not made for her. Forms were written in a language she could not read. Free-standing machines in hallways slowed her down as she followed nurses’ voices through noisy hallways into cluttered examination rooms. Armed with these biases about the inaccessibility of the world around us, I remember the awe I felt walking into the school where my aunt teaches children with multiple disabilities, Lavelle School for the Blind in New York. For the first time, I saw a world in which students who used wheelchairs could easily roll through hallways, one where students who were blind could play with balls that had bells. Now, as a medical student, I am drawn to orthopaedic surgery because of the potential that it holds to increase the ease with which people move through the world. Our procedures are often essential in improving the quality of life of persons with disabilities. However, this care may be inherently inaccessible because of the many obstacles—environmental (e.g., elevators without braille numbers in a clinician’s office), interpersonal (e.g., clinicians who talk to people with disabilities using “baby talk”), and infrastructural (e.g., a paucity of training for clinicians on working with patients with a variety of disabilities)—that patients may face when interacting with the health-care system. Background The World Health Organization frames disability as a state that results from an interaction between health conditions and contextual factors (e.g., personal factors, such as age, social background, and education; and environmental factors, such as social attitudes and terrain)1. In the U.S., 1 in 4, or 61 million, adults live with a disability2. Disability can take many forms, with examples including a physical disability (e.g., spinal cord injury), developmental disability (e.g., autism), or sensory disability (e.g., blindness). Additionally, individuals with an impairment of the musculoskeletal system that affects daily functioning may experience temporary or long-term disability. Indeed, the 2016 Global Burden of Disease Study identified that many of the top causes of years lived with disability in the U.S. were forms of musculoskeletal impairment: low back pain (no. 1), other musculoskeletal disorders (no. 4), neck pain (no. 6), and osteoarthritis (no. 12)3. Hence, orthopaedists may encounter individuals with disabilities under many circumstances in routine practice, such as a surgical consultation for an older adult with low vision and hip pain related to osteoarthritis, a young adult with a spinal cord injury and rotator cuff pathology, and a middle-aged adult with chronic low back pain. In September 2023, the National Institutes of Health designated people with disabilities as a population with health disparities, alongside others such as racial/ethnic and sexual/gender minority groups4. As a group that experiences substantial health inequities, individuals with disabilities have reported dissatisfaction with the information received about their conditions, the costs of care, and the ease with which they are able to visit a clinician5. This designation highlights the reality of the lived experience of many patients seeking orthopaedic care. Orthopaedists hold the power to help demolish current barriers that marginalized patient populations face when attempting to access care. As a call to action, we provide examples of solutions addressing environmental, interpersonal, and infrastructural factors that are barriers to health equity for patients with disabilities. Environmental Factors Although the Americans with Disabilities Act requires that hospitals and doctors’ offices be designed to be accessible for people with disabilities, barriers often persist in health-care environments. Beyond ramps, clinicians and those they work with to design their facilities should incorporate principles of universal design, which focuses on creating spaces that are inclusive and accessible to all people who use them. Specifically, they may ensure that patients can access all parts of their facilities (e.g., hallways, examination rooms) and equipment (e.g., examination tables, weighing machines)6. Clinicians may also choose to highlight the importance of inclusion in their office through a display or other means of communicating nondiscriminatory policies7. Finally, it is worth remembering that not all patients with disabilities have the same needs (e.g., patients with hearing impairments may need sign language interpreters, patients with autism may need quiet spaces), and we should strive to help all patients feel cared for. Interpersonal Factors Some individuals may hold an implicit disability bias, or the belief that the life of a person with a disability is less valuable than that of a person without a disability8. Clinicians who hold such an unconscious bias may joke that a wheelchair user is “zooming around” or talk to someone with a disability in “baby talk.”7,9 We all can examine our biases, both conscious and unconscious, through self-reflection and using tools such as the Harvard Implicit Assessment Tests10. Efforts should also be invested in workforce diversity that includes disability status, as doing so helps to improve not only patient outcomes, but also clinicians’ productivity and performance. Indeed, when clinicians and staff are reflective of the populations they care for, patients feel more supported, fortifying the patient-provider relationship and subsequently leading to better outcomes11. Infrastructural Factors Ultimately, sources of inequitable care for people with disabilities are deeply ingrained in our health-care system, and we all must play a role in creating infrastructural change. Within health systems, clinicians must be trained to improve care for populations that are systematically marginalized, such as patients with disabilities12. A particularly effective training could be led by or highlight the voices of people with disabilities and may include case studies, didactics, or simulations12. Nationwide, disparities may be exacerbated by the fact that patients with disabilities often have Medicaid insurance, which further limits access to care. One study noted that 40% of orthopaedic surgeons were hesitant to care for patients with Medicaid, potentially because of low reimbursement rates and the additional time and resources that may be needed to comprehensively care for a patient with social complexity13,14. As such, reimbursement models may need to be restructured to ensure that clinicians are not penalized for providing orthopaedic care needed by patients with disabilities. Additionally, the systematic and routine capture of disability status in health-care documentation and national data are necessary to guide efforts to identify and address disparities experienced by patients with disabilities. Accessible Care for All Patients Patients with disabilities commonly seek orthopaedic care but often encounter many barriers to accessing these services. By taking steps to modify environmental, interpersonal, and infrastructural factors, orthopaedists can increase equity for this population that faces notable health-care disparities. As a medical student, I hope to use my voice to highlight the lived experiences of my aunt, and many others in the disability community, in order to equip orthopaedic surgeons with the tools they need to provide all patients with equitable and transformative care.