How Do Family Medicine Residencies Identify and Accommodate Residents with ADHD?

What you need to know

• Attention deficit hyperactivity disorder (ADHD) is common among medical residents, with over 60% of family medicine residency programs reporting having had a resident with ADHD in the past 3 years.

• Most residency programs identify residents who need ADHD accommodations reactively (after performance issues arise) rather than proactively.

• Once identified, most programs implement accommodations for residents with ADHD within 1 month.

• The most common accommodations provided are interpersonal supports like mentoring and changes to precepting approaches.

• There are opportunities for residency programs to take more proactive approaches to identifying and supporting residents with ADHD earlier in their training.

Background on ADHD in Medical Training

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that affects a person’s ability to focus, manage time, and control impulsive behaviors. For medical residents, who must juggle multiple competing priorities while caring for patients, ADHD can create significant challenges.

Research suggests ADHD is relatively common among medical trainees. One study found that about one-third of medical students receiving disability accommodations had ADHD. Despite this prevalence, there are barriers that may prevent residents from disclosing their ADHD diagnosis or seeking accommodations. These include fears about stigma, concerns about professional consequences, and uncertainty about what accommodations are available.

When residents with ADHD do not receive appropriate support, it can lead to difficulties completing tasks on time, organizing priorities, and managing long-term projects. These challenges may be misinterpreted as professionalism issues rather than symptoms of ADHD. This puts residents at risk of facing disciplinary action or remediation before receiving the accommodations they need to succeed.

Given these high stakes, it’s important to understand how residency programs approach identifying and accommodating residents with ADHD. This study aimed to assess current practices among family medicine residency programs across the United States.

How the Study Was Conducted

The researchers surveyed family medicine residency program directors across the U.S. using the Council of Academic Family Medicine Educational Research Alliance (CERA) survey. Out of 672 eligible programs, 298 program directors responded (a 44.3% response rate).

The survey asked program directors about:

• When residents with ADHD are typically identified as needing accommodations
• How quickly accommodations are implemented once identified
• What types of accommodations are provided
• How recently the program has reviewed its technical standards (the essential functions and abilities required of residents)

The researchers analyzed the survey responses to understand patterns in how family medicine residencies approach ADHD identification and accommodation.

Key Findings

ADHD is Common in Family Medicine Residencies

Over 65% of program directors reported having a resident with ADHD in their program within the past 3 years. This confirms that ADHD is relatively prevalent among family medicine trainees.

Most Programs Identify ADHD Reactively

The researchers categorized programs’ approaches to identifying residents who need ADHD accommodations as:

1. Early/proactive: Identifying needs during the interview process or orientation
2. Reactive: Identifying needs after a critical event or milestone evaluation
3. No identification: Program directors were not aware of any residents needing accommodations

Only about 1 in 6 programs (17%) took an early/proactive approach. Most programs that identified residents needing accommodations did so reactively (43%). The remaining 39% of program directors were not aware of any residents needing ADHD accommodations.

This suggests there are opportunities for more programs to take proactive approaches to identifying residents who may benefit from ADHD accommodations earlier in their training.

Rapid Implementation of Accommodations

On a more positive note, once the need for accommodations was identified, most programs (85%) implemented them relatively quickly - within 1 month. This suggests that when residents do disclose their ADHD and request support, programs generally respond promptly.

Programs that identified accommodation needs early/proactively were even more likely to implement them quickly compared to programs with reactive identification. This highlights a benefit of proactive approaches - they allow accommodations to be put in place before performance issues arise.

Common Types of Accommodations

The most frequently provided accommodations for residents with ADHD were:

1. Interpersonal accommodations (42% of programs): This includes supports like mentoring, job coaching, and changes to precepting approaches.

2. Environmental accommodations (26% of programs): For example, providing a quieter workspace.

3. Assistive accommodations (22% of programs): Such as providing timers, organizational apps, or calendars.

About 15% of programs said they provided informal accommodations “constructed on the fly.” No programs reported denying accommodation requests from residents with ADHD.

Technical Standards Review Not Linked to ADHD Practices

The researchers hypothesized that programs who had recently reviewed their technical standards (the essential functions required of residents) might be more proactive about ADHD identification and accommodation. However, they did not find a significant relationship between recency of technical standards review and ADHD practices.

Less than half of programs had reviewed their technical standards within the past year. The researchers suggest more frequent review could help programs clarify job requirements and reduce unintended discrimination.

Lingering Stigma

While 89% of program directors said they would rank residency applicants without regard to an ADHD diagnosis, 8% said they would rank an applicant with ADHD lower, and 2% said they would not rank them at all. This suggests there is still some stigma surrounding ADHD in medical training that needs to be addressed.

Implications and Recommendations

This study reveals both encouraging practices and areas for improvement in how family medicine residencies approach ADHD. On the positive side, most programs implement accommodations quickly once a need is identified. However, there are clear opportunities for more proactive identification of residents who may benefit from ADHD support.

The researchers offer several recommendations for residency programs:

1. Take a more proactive approach to inviting residents to disclose ADHD and request accommodations. This could involve:

   • Explicitly stating the program’s commitment to inclusivity and support for neurodiversity during orientation
   • Normalizing discussions about learning differences and available accommodations in individual meetings with residents
   • Providing multiple opportunities for residents to disclose ADHD or other conditions that may require accommodation

2. Review technical standards more frequently to ensure they accurately reflect essential job functions and do not unintentionally discriminate.

3. Develop a “toolkit” of effective ADHD accommodations tailored to the specific demands of residency training. Programs can learn from each other about successful support strategies.

4. Work to reduce lingering stigma around ADHD through education and open dialogue. Emphasize that with appropriate accommodations, residents with ADHD can excel in their training and careers.

5. Consider implementing universal design principles that can benefit all residents, not just those with ADHD. For example, providing clear written instructions and checklists can help everyone stay organized.

Conclusions

• ADHD is common among family medicine residents, affecting trainees in about two-thirds of programs surveyed.

• Most residency programs take a reactive rather than proactive approach to identifying residents who need ADHD accommodations. This may result in residents struggling before receiving needed support.

• Once identified, programs generally implement accommodations quickly. The most common accommodations are interpersonal supports like mentoring and precepting changes.

• There are opportunities for residency programs to take more proactive approaches to identifying and supporting residents with ADHD earlier in their training.

• Reducing stigma and creating an inclusive environment where residents feel comfortable disclosing ADHD is important for ensuring all trainees can thrive.

By implementing best practices for supporting residents with ADHD, family medicine residency programs can create more inclusive training environments and set all of their residents up for success. This benefits not only individual trainees, but also the patients and communities they will go on to serve as family physicians.