In this podcast, Dr. Singh discusses his work in advocating for equal access in medical education and his success with ensuring competencies around the care of patients with disabilities are taught to every medical student in India.
Satendra Singh, MBBS, MD, University of Delhi
Episode 8, Transcript
DocsWithDisabilities Podcast #8
Dr. Satendra Singh
Doctors with disabilities exist in small but measurable numbers. How did they navigate their journey? What were the challenges? What are the benefits to patients and to their peers? What can we learn from their experiences? My name is Lisa Meeks and I am thrilled to bring you the Docs with Disabilities podcast.
Join me as I interview Docs, Nurses, Psychologists, OT’s, PT’s, Pharmacists, Dentists, and the list goes on. I’ll also be interviewing researchers and policy makers that ensure medicine remains an equal opportunity profession.
Lisa Meeks:
We are excited to bring you a special international episode of the Docs with Disabilities Podcast. Today, I get to chat with Dr. Singh, about his incredible victories of late, including the addition of 8 disability focused competencies to the medical education curriculum in India. Let’s listen, or read along, as Dr. Singh talks about these new competencies within the new curriculum.
Satendra Singh:
We in India modified our curriculum after 22 years, and now the curriculum is a competency based medical education curriculum. Even in the previous curriculum, the similitude of the elephant in the room has been used to chronicle the experiences of patients with disabilities within the medical profession that she is present but unnoticed. And that was a reason why we for a very long time use the medical model of disabilities in our curriculum. So, when our curriculum was updated again, they came up with a new competency-based medical education curriculum, but unfortunately it still did not include the human rights approach towards people with disability. And during that time, it was just a sheer coincidence that I was working on this project, “Disability-inclusive Compassionate Care,” where we were developing competencies within the Indian setup and we had focus group discussions with three key stakeholders.
The dominant key stakeholders were doctors with disabilities because they were never heard before. The second category was disability rights activists, and the third one was health professional educators. So, we had focus group discussions with these three key stakeholders, and based on that we prepared 52 competencies. Then we shared these with a larger audience. We shared it with people around India. We took their feedback, and based on that feedback we further revised these competencies into 27. And these were categorized into the five roles expected of an Indian medical graduate, which in a way is in sync with the six ACGME core competencies as well as the seven physician roles in CanMEDS. So that way, we believe that they are in sync with international standards. But the big question was that whether the Medical Council of India will accept these recommendations or not. We were fortunate that you know, two statutory bodies within India, the Chief Commissioner for persons with disabilities and the state commissioner of person with disabilities, they made recommendations to the Ministry of Health in India and they said that this new law, our new Rights of Persons with Disabilities Act, it very clearly states that all education institutions, they must incorporate human rights approach within their curriculum.
So, based on that, it was sort of easier for us to convince those people. And in a very quick chain of events in July, the Medical Council of India, they wrote back to me that we would like to include these competencies within the one month of mandatory foundation course. That's how in the foundation course we have seven allotted hours for disability competencies and all 530 medical schools in India. They took these seven hours for disability competencies in this August.
Lisa Meeks:
What Dr. Singh has accomplished, the universal teaching of a disability curriculum, is incredible. To have a comprehensive plan that each medical learner receives regardless of where they train, that's a win for Indian medical students and patients.
Although this has yet to be accomplished in the US System, there are individual programs who are developing modules and individual course curricula for teaching about working with patients with disabilities. Dr. Singh articulates the value of these competencies and provides an example of how just one can make a world of difference in the quality of care for patients with disabilities and how people with disabilities helped inform the development of these competencies.
Satendra Singh:
This was really very important because if I give you one quick example of one of the competencies in the interpersonal communication skills role, it was demonstrating the use of verbal and nonverbal empathetic communication techniques while communicating with patients with disabilities and their caregivers in a manner acceptable to the specific disability culture. Now this has two very important components. In one of our focus group discussions, we had a representative from deaf blindness community and he specifically emphasized on this point that verbal communication is fine but it has to be non-verbal empathetic communication. Moreover, during our discussions, we also came up with this thing that you know, it has to be acceptable to the specific disability culture. Deaf people, they do not like the word hearing impaired. They believe in their Deaf culture with a capital D, and the same is true with autistic people. Also, they prefer that terminology. When we compare with the other international norms, like persons with disabilities, vis-a-vis disabled persons. So, when we are advocating for the inclusion of human rights approach, we have to include each and every person from the disability sector. And that is why the specific use of the word specific disability culture has been part of the competencies now.
Lisa Meeks:
Dr. Singh is a force of nature and an incredible advocate for disability inclusion. Having competencies instilled across all Indian Medical Colleges was an enormous success, but he didn’t stop there. Instead he worked to ratify the laws and change the technical standards for entrance to medical school in India. Dr. Singh talks about how he tapped into his quickly growing network leveraging international efforts to support his goals.
Satendra Singh:
Well, so in India we, in 2016 we have our new disability legislation, which was based on the ratification of United Nations Convention on the Rights of People with Disabilities. But then as far as medical education is concerned, the Medical Council of India, which is a statutory body for medical education in India, they came up with -- you can understand this as a technical standard at a central level rather than an institutional level. So, they prepared those set of guidelines. There was a selected lot of people, you can say six experts, and they decided on the twenty-one disabilities, which are there in our legislation. And they believed, without the support of literature which category of people with disabilities may or may not complete medical education. And without any evidence, they formulated those guidelines and which debarred a lot of candidates with disabilities. For example, there was a debar on more than 80% of disabilities. They were not allowed to enter medical school. They put a bar on dyslexia initially. But when we challenged, they included dyslexia, but then they put a bar on dysgraphia, which they have no reason why they have done so because we are moving to an era of electronic health records. So how can dysgraphia can be a bar to become a future doctor?
How does this matter? Because these days we are talking about electronic health records. So, this requirement becomes redundant. Moreover, they also insisted that a doctor must have both hands intact. Now this is very surprising because there are instances of several doctors with only one hand who have graduated from places like Duke University and the University of Cincinnati. And it depends upon the candidate, whether he wants to go to a surgical field or the medical field or a teaching field, wherever, or research. So how can they put a bar to all the people that you need to have a both hands intact? It defies any logic and there was no evidence for them.
So fortunately, I contacted the international experts, and I'm very thankful to you Dr. Meeks for supporting me in this battle. And also, the Association of Academic Physiatrists from USA, the Disabled Doctors Network from United Kingdom, and the Doctors with Disabilities organization from Australia. All of them supported me with the case studies of people who are having these types of disabilities and they have become successful doctors in each of these countries. We submitted them to the Honorable Court because our laws, they are very much clear that it has to be based on the Convention of the Rights of People with Disabilities. And we do have a few landmark cases from the judiciary. So, we have submitted to them the best possible international evidence. We have submitted to them the General Medical Council of UK’s new guideline which supports disabled learners. I’m talking about the Welcomed and Valued document, which is a very huge document and which is a very supportive document because it is the medical council there in the UK, which is supporting disabled learners.
And if you look at how the document was prepared, there were a lot of group discussions and focus group discussions happening with the medical educators, disabled people. And they actually gave their ideas and the formulation of those guidelines, and that's how they created it. And in case of the Medical Council of India, they just did the opposite of that. So that is one document which will give enough evidence is that how we can support disabled learners and both undergraduate and postgraduate medical education. In addition, you yourself have come up with the AAMC guidelines on the lived experiences of people with disabilities, which is again a very important document because many times we often, specifically I have faced this question in India from many of the top-rated doctors. They ask me, what is the value of disabled people in Medical Education? How will society benefit from that?
Lisa Meeks:
As we continued our conversation, I ask Dr. Singh how these changes in technical standards and new disability legislation apply to actual cases of learners with disabilities in India and how the inclusion of doctors with disabilities helps to inform patient care.
Satendra Singh:
We recently had a case where there was a candidate with a psychological disability and he was denied, his admission was canceled, and he sued in the Court of law and honorable Court said that he has his right to become a doctor, which is a very important judgment case in India. He has been allowed admission in a medical school. So, he will be starting in the medical school, but the overall guidelines of the Medical Council of India, they still debar that. So, since the highest ethics court in India, the Supreme Court of India has said that they will not interfere in this decision because that candidate has a right to pursue medical education. In that sense, it becomes imperative for the Medical Council of India to at least upgrade their guidelines pertaining to candidates with mental illness.
People are now scared that you know, why do you want people with psychological disabilities into medicine? And my answer to them is the same, which it resonates with me as well because I have a lived experience of physical disability. We have experienced that pain, we have experienced the disability, and these are the experiences which make us more humane and more empathetic in a patient encounter.
Satendra Singh:
The purpose of medicine is not only curing but the purpose of medicine is also caring. And when we say care we largely mean compassionate care. And this compassionate care comes from the experience of vulnerability.
Now if you look at the competency and the CanMEDS of being a health advocate, which is more or less same with competency of practice-based learning and improvement. And it is the same as in the Indian Medical Graduate competency of lifelong learner. When we interacted with those three focus groups and people came up with this particular competency that an Indian medical graduate must advocate social inclusion by raising awareness of the human rights of persons with disabilities.
Satendra Singh:
There were cases of physical disabilities, and they have been granted a medical admission by the honorable Court because they agree with... Our evidence that 80%, from where they come up with this magical number of 80%, which is really ridiculous because does that mean that people having a disability of 79% are allowed and those having 81% are not allowed? They don't have any justification for that number. So, in that particular case, the Medical Council of India has a mandate only for that particular guideline that people with mobility impairment, even if they have more than 80% of disability, then they will assess the candidate based on their functional competence. And that was the same logic which we have been arguing with Medical Council of India that you need to do ability assessment and not a disability assessment. With the help of assistive devices, with the help of reasonable accommodations, people with any type of disability can pursue medical education with flying colors.
So, they have amended one particular step. So, there is a relief to those who are having mobility disability, but other types of categories are still there. I have challenged all the policy decisions. So, individuals are getting benefit from the Courts, but they are only one or two individuals. Definitely they are getting benefits. I'm hopeful there will be changes in all policy documents and they will involve doctors with disabilities, all disability experts when they are framing those guidelines. Because nothing about us without us.
Lisa Meeks:
I am just sitting here with the biggest smile on my face because you just, you are a force to be reckoned with. And yet, you know, it's, when I look at your accomplishments and then having met you, you're so humble and you're so collegial and so easy to work with. And at the same time, you are this incredible force for change in India. And I'm always amazed by how much you get done in the course of a day. I don't know if there are actually two of you and you just switch off.
Satendra Singh:
I wish I had clones, identical twins. But again, I would like to clarify it over here that there are many people, many silent supporters in this journey. The only reason is that I am more vocal and somebody has to be more vocal because it is important that you know that in the capacity of which I am right now, I'm sitting in the capital of India. I'm also a member of the Delhi Medical Council, which is a statutory body for medical negligence cases in the Delhi. So, in that capacity, people have very high hopes from my stature. And there are many people who have different types of disabilities, but again, because of the societal pressure or the stigma and discrimination, they do not want to come out and open, but they are supporting me in the struggle.
So, I'm happy with that. I'm happy to lead their battle. But again, this boils down to a very important question, that is the question of embracing their disability identity. Many times, I've seen many top doctors who just shy away from embracing the concept of their own disability identity and they say that this is just, I do just only have a minor thing.
The reason why I'm more vocal about this issue is that it took me a very long time to identify my disability identity. And that’s how I realized lately, you know, that my power of perseverance and resilience is actually because of my lived experiences of discrimination and disability. So, people who are facing oppression, they have to stand up for their own rights.
Even if they cannot walk, it doesn't mean they cannot stand up for their rights. Even if they can't see, it doesn't mean they don't have any vision. We can only support these learners, but ultimately, they have to raise their own voice.
Lisa Meeks:
I want to switch and talk to you as a physician with a disability. What do you think are the most important things to remove barriers and facilitate success when it comes to entering medical education or health science education as a person with a disability?
Satendra Singh:
Well I think the most important thing for any aspirant who wishes to become a future doctor is to be clear about their own goals. Nowadays, there are so much of reasonable accommodation which is available. So, any type of disability is not actually a barrier. The only thing is perhaps you need to know a little bit about what your rights are, what type of reasonable accommodations you require. The problem is that many of the candidates with disabilities, perhaps they again try to ignore their own disability, and they still think disability from that charity approach and not from a human rights approach. Definitely, it’s too early for them to understand all of this. But again, if they're reading, at least they need to know what are the right resources, what is the type of specialty they are looking for.
They need to identify their strengths and weaknesses. Going into medical education, Graduate Medical Education, may not be that difficult, but when they would like to pursue their specialty, again then they have to be a little bit careful about which specialty would they like to take because they have to play to their strengths rather than their weaknesses. And as I said, they have a social responsibility also towards other doctors as well as patients with disabilities as well. So, they need to be clear about their goals. They need to know where to seek those accommodations when they are joining a medical school, that is very important. For example, people who have invisible disabilities like dyslexia or those who are having mental health issues, they still are skeptical about the whole issue, and that is why the podcast which you are doing with various people, this will be of great resource to other people. You'd never know how this will affect policies, and subsequent scholarship which will be emanating out of this thing will definitely help to make those policy decisions.
But just the mere example of people who are having these types of disabilities and who are working to their profession in the medical field is I think a big impetus for other nondisabled people to change their mindset. So, a huge responsibility rests on the shoulders of these learners with disabilities that they have to be a role model because many people will be following their path. So, I think in that way our job becomes more difficult and more responsible because we have to become a role model in front of them. And that is how we increase our tribe. It will create a ripple effect, but it all depends upon how you handle your future patients, your future caregivers, because that will create that trust and bonding with them. The word of mouth will spread and the biases and prejudices which are prevalent in the society that sometimes question the abilities of physicians with disabilities, they will disappear.
Lisa Meeks:
That's really well put. Your work has made a global impact. Because of your advocacy and going to the council about this 80%, there was this spark really that happened internationally to support your efforts. And because of this and because of this experience, it really highlighted the differences country-to-country and the way that medicine and individuals with disabilities in medicine are being viewed and treated and has really driven this idea about the international medical advisory group to serve sort of as a United Nations if you will, to come up with a set of international standards that say across the majority of countries, these are the practices that are happening. And certainly, some countries will be more progressive and others will just meet that floor if you will. Your case and your drive to change the practice in India has really sparked this need for an international set of guidelines. And so, you really have been the impetus for the discussion that's now occurring about an international council and international guidelines. I hope you know how much your work is impacting the future and obviously you will be part of any international efforts for developing guidelines.
Satendra Singh:
Doctor Meeks, with great humility, I would like to disagree in your initial part that it is entirely my work which has shaken the globe. Actually, and it all started with -- you’re very humble -- you started the Hashtag DocsWithDisabilities and during that time in India in 2018, around February 2018, these guidelines in India for medical learners were being prepared. At the same time, you came up with the guideline accessibility, inclusion and action in medical education, which I often quote wherever I go.
Lisa Meeks:
You're never doing this alone. My co-PI, Neera Jain and then my partnership with Pam Liao from the Canadian Association of Physicians with Disabilities. I just want to certainly acknowledge that both of these efforts were a team work, but thank you.
Satendra Singh:
Yeah. Because during the same time, you know, the Welcomed and Valued document was being prepared. So, you were doing this work in the USA. In the UK, discussions were happening. And during the same time, the so-called “experts” in India, they were preparing those discriminatory guidelines. And that was the impetus for me to take this forward. And let's go back to 2019, and in 2019 there was a great paper in Academic Medicine on technical standards, which questioned the same thing which I was challenging in India.
These are very exciting times. Somebody has said that when your intentions are good, noble, and pure, the universe conspires. And I believe if you look at this, the things happening in the US at that time, in the UK at that time, in India at that time, and when I was looking for support in my petition against the Medical Council of India, again, two organizations of Docs with Disabilities, Disabled Doctors Network in UK and Doctors with Disabilities in Australia, they also joined in. So, this was perhaps the time that is so exciting. People are talking about these issues. And huge thanks to the folks in United States of America that they are writing on these issues regularly. They're capturing the imagination of academics as well as activists all over the globe.
So, I think these efforts which are happening over here, we can certainly bridge this divide. And that is why an international coalition is the need of the hour. And recently even at the AMEE conference as well, there was a specific panel discussion where there were top people from the medical councils of three different countries. They came over there and presented their findings. So already people are collaborating, already there is a buzz. So, I hope these are really exciting times as far as disability education and disability rights are concerned.
Lisa Meeks:
Well thank you for that. I love that, when your intentions are pure. I think that, you know, that is what I have appreciated so much. We talked about this in Chicago, that when I meet people that are doing the same work, they're doing the work for the right reasons or they're really focused on the human value part of it, the contribution of all people. I agree, I think that, you know, the universe is conspiring in a really good way. The excitement I feel when I meet with like-minded researchers and physicians from across the globe is just, it's so motivating. It's a really good group of people that are all over the world doing this work. And so being able to connect individuals has been an honor.
Lisa Meeks:
Thank you so much for agreeing to talk to me because I want people to be able to connect the advocacy work to actual change in practice and inclusion, and you certainly are a role model for that. Would you mind sharing your Twitter handles so that our listeners can follow you? I know you're very active on Twitter. You share not only the things that you're doing but you are really great at sharing all of the things that are going on globally and so there's a lot of reasons to follow you on Twitter.
Satendra Singh:
Thank you so much Dr. Meeks for that. My Twitter handle is @drsitu, which means Doctor Situ. so, people are more than welcome to follow me, and I thank you so much for having this conversation. And I would like to thank you for this kind of work which you are doing, and you actually, you might not be knowing about this. And I am again repeating this, that particular #DocsWithDisabilities and #NursesWithDisabilities is actually creating ripples. I talked about that disability identity, and probably people are relating it with that. And in that we will need more such conversations, and thank you so much for having this podcast series because now we can have experiences of so many physicians with disabilities and this is very important in changing mindsets.
Lisa Meeks:
Changing the culture.
Satendra Singh:
It does.
Lisa Meeks:
Thank you so much.
Satendra Singh:
My pleasure Dr. Meeks.
Lisa Meeks:
Thank you for joining us for today’s podcast. As you heard, international efforts are underway to help move the needle towards global inclusion for qualified learners with disabilities. Follow Dr. Singh, and all of our interviewees, on social media to keep up with the latest developments in this area.
Kate Panzer:
This podcast is a production of the University of Michigan Medical School, Department of Family Medicine, MDisability initiative. The opinions expressed in this podcast do not necessarily reflect those of the University of Michigan Medical School. It is released under a creative commons, attribution noncommerical, nonderivative license. This podcast was produced by Lisa Meeks and Kate Panzer.
*This podcast was created using excerpts from the actual interview and is representative of the entire conversation. Interviewees are given the transcript prior to airing. Some edits may reflect grammatical and syntax adjustments for transcription purposes only.