Patients with physical or mental disabilities present special challenges, but you can take steps to meet their needs and avoid liability.
An Oklahoma internist will never forget the wheelchair-bound patient who came in carrying pictures of the pressure sore on her buttock.
The pictures alone, the internist knew, were insufficient to make a diagnosis. But without extra help or a lift, she was unable to place the woman on the exam table to see the lesion firsthand. Frustrated, the physician suggested that the patient return with family members to help with the transfer. The patient balked, however, and eventually filed a complaint against the doctor for violating the Americans with Disabilities Act of 1990, the landmark law forbidding discrimination based on disability.
"My office manager had to go to an arbitration meeting, where we agreed either to invest in a lift, which wasn't economically feasible, or to transport future wheelchair patients to the nearby ED," says the internist, who requested anonymity.
Although it's been nearly two decades since the ADA was passed, doctors continue to be cited for violations. As "public accommodations" under Title III of the ADA, doctors' offices are required to take certain steps to ensure diat people with disabilities-whether physical or mentalreceive treatment equal to that of nondisabled patients, to the extent possible. Removal of architectural barriers that impede physical access to the office is a key part of complying with the law. But, as the Oklahoma internist found out, that alone is not enough.
Noncompliance costs money
Violations of the law can be costly-up to $100,000 per incident for repeat offenses. But die ADA is not the only legal concern associated with this population. Physicians may also face a greater malpractice risk when something goes awry with a disabled patient.
"We refer to such people as 'eggshell patients,' " says Kevin Quinley, a risk management specialist in Fairfax, VA, and author of Bulletproofing Your Medical Practice (SEAK, 2000). "For them, a complication or adverse outcome might be far more devastating than for someone without a physical or mental encumbrance. That fact not only affects whether an incident is litigated, but also the potential damages involved."
Being extra careful to fulfill your obligation to provide genuine access and equal treatment not only constitutes good risk management, but also good medicine.
Barrier removal and beyond
Physicians who own their own buildings or are responsible for design changes have generally succeeded in making their offices more accessible to people with disabilities, especially those with mobility impairments.
They've added disabled-only parking spots, installed ramps in places where stairs interrupt a travel route, retrofitted entrances and doorways, and, in some cases, built or redesigned rest rooms and installed accessible drinking fountains and public telephones. In general, such modifications are considered "readily achievable"-able to be completed without undue difficulty or expense. (see die box on page 44 to learn more about specifications. You can also find a checklist of modifications at www.usdoj.gov/cn/ada/checkweb. htm.)
But physicians have done less well in instituting changes that exceed these minimal requirements for physical accessibility, says Margaret A. Nosek, executive director of die Center for Research on Women with Disabilities, at Baylor College of Medicine, in Houston.
"A doctors office may have a ramp and designated parking spaces for die disabled, but still be turning away patients because it isn't equipped to handle them once they get inside," Nosek says. The Center can document "hundreds and hundreds" of such cases, which violate the ADAs nondiscrimination provisions. The most prevalent "accessibility" issues in medical settings are "lack of effective communication, lack …