Psychiatry residents occupy a unique place in the medical education system. Though technically classified as employees of a hospital or other institution, in reality they are both employees and students. Alternately referred to as “house staff,” they function as “in house” physicians for the hospital under the direct supervision of fully trained doctors. Implicit in this arrangement is that recent graduates of medical school work longer hours with significantly lower pay in order to gain knowledge, education, experience, and, ultimately, certification in their particular specialty.

In order to graduate and be eligible for specialty certification in psychiatry, resident doctors are required to demonstrate competency in designated core areas of clinical practice and to pass academic and functional testing required by their residency program and by the Accreditation Council for Graduate Medical Education (ACGME). Because of the emphasis on demonstrating “core competency,” psychiatry residency programs now must be more diligent in documenting a resident’s knowledge base and clinical competence in order to graduate the resident and be able to obtain accreditation.

While there has been an increase in the requirement for documentation of resident physician competency, there has been a parallel increase in the recognition of alternative learning styles and of the persistence into adulthood of diagnoses such as attention deficit hyperactivity disorder (ADHD). Section 504 of the Rehabilitation Act of 1973 (1) and the Americans with Disabilities Act (ADA) of 1990 (2) provide for accommodations for employees or students with a documented learning disability. However, there is very little in the literature regarding guidelines for accommodations, specifically for resident physicians with ADHD.

With the improvement in recognition of ADHD as a disorder persisting into adulthood and the increase in demand for objective evidence of competency in core areas of knowledge, one would anticipate a corresponding increase in requests for accommodations from residents diagnosed with the disorder. In this article, we discuss ADHD as a disorder requiring accommodations, review the assessment and appropriate documentation of ADHD, examine the laws and guidelines applicable to resident psychiatrists, and discuss how accommodations might be implemented in a confidential and appropriate manner.

The Diagnostic and Statistical Manual IV (DSM-IV) describes the essential feature of attention deficit hyperactivity disorder as “a persistent pattern of inattention and/or hyperactivity that is more frequent and severe than is typically found in individuals at a comparable level of development” (3). Symptoms of ADHD include the inability to consistently sustain or apply concentration, distractibility, impulsivity, difficulty completing tasks, restlessness or fidgetiness, procrastination, forgetfulness, careless mistakes in work or school, difficulty following directions, becoming easily bored or impatient, and blurting out or interrupting others.

Previously thought to be a childhood disorder, it is now known that ADHD symptoms persist in up to 60% of adults who exhibited symptoms as children (4). Evidence of the biological and genetic nature of ADHD continues to mount with genetic, neuroimaging, and neurological studies all supporting difficulty in cognitive executive functioning (5, 6). Deficits in executive functioning are linked to lack of availability of dopamine and norepinephrine in the prefrontal cortex (7). These differences in executive functioning exist independent of intelligence but they have been linked to problems in academic performance (8). Adults with ADHD often report impatience, heightened anxiety responses, emotional reactivity, difficulty controlling anger, poor organizational skills, impulse control problems, distractibility, difficulty attending to details, decreased attention span, lack of time sense, chronic lateness and forgetfulness, low self-esteem, chronic boredom, and difficulty with prioritization. Adults with ADHD are more likely to have comorbid affective and/or anxiety disorders, substance abuse problems, difficulties in relationships, and personality disorders. Symptoms of ADHD can cause difficulty in accurate measurement of academic competency and knowledge; many of these symptoms could cause impairment in the ability to master core clinical competencies in psychiatry residency.

There are multiple guidelines for the assessment and documentation of ADHD. The requirements of the National Board of Medical Examiners for the United States Medical Licensing Examination (USMLE) include the following (9):

In situations where co-occurring disorders or learning disabilities are documented, these must also be taken into account and factored into the decision about the appropriate accommodations. However, there must be a reason and rationale for specific accommodations for an individual based on their particular disabilities and/or weaknesses.

Academic achievement in medical education is measured in part by performance on standardized tests. The Scholastic Aptitude Test (SAT) is required for admission to college and the Medical College Admission Test (MCAT) is required for admission to medical school. Then, there are a series of stepped board examinations culminating in specialty board certification. It generally is accepted that ADHD can be predictive of academic difficulty and poor school performance in children and adolescents (10–12). Although there are no known published data concerning the impact of ADHD on higher-level achievement tests or other measures of performance at the professional level, there is evidence that adults with ADHD demonstrate a variety of general and specific performance deficits compared with age and education-matched adults without ADHD (13).

A recent meta-analysis of studies by Hervey et al. (14) compared individuals with ADHD with healthy subjects across neuropsychological domains that measured attention, response inhibition, memory, processing speed, and global intelligence. The authors made several observations that shed light on the possible contribution of these deficits to the test-taking environment. They noted that patients with ADHD performed relatively poorly on tests on which there were verbal rather than visual presentations of stimuli, particularly if distracting stimuli were added to the verbal presentation. Oral board exams in psychiatry are likely to be challenging, as would be testing conditions in which there are significant distractions (e.g., multiple people in a room, excessive noise, and multiple interruptions). These authors also found that ADHD patients’ performance declined as task demands increased in their complexity, time requirements, processing speed, and demands upon motor functioning. As the number or difficulty level of these conditions increased, there was a corresponding decrease in performance. In particular, tests requiring speeded processing under timed conditions, such as the PASAT (Paced Auditory Serial Addition Task), produced larger differences between ADHD patients and healthy subjects compared with tests without time limitations. Furthermore, others who reviewed meta-analytic neuropsychological data on performance among adults with ADHD noted that findings for this population may be confounded by differences among subtypes of the disorder as well as comorbid disorders (15).

In addition to an examination of empirical data, it is important to note that the Supreme Court has ruled that under the ADA, major life activities must be evaluated in the mitigated or treated state (16). It is important to examine the extent to which stimulants and other treatments for ADHD mitigate cognitive performance. Adult ADHD patients taking methylphenidate have shown improved response inhibition, distractibility, verbal memory, spatial working memory, motor speed, processing speed, and visual scanning (17–19). The question of whether these medication-associated improvements result in better real world academic performance has been addressed only in children with ADHD (10–12). Because pharmacotherapy can alter all phases of learning and not just test performance, it is not clear whether the demands of standardized testing are fully mitigated for adults receiving medication. However, given that accommodations must be granted based on the mitigated or treated state, it would seem reasonable that a discussion of the effects of treatment for the particular resident should be included in the evaluation and recommendations of the qualified diagnostician.

Section 504 of the Rehabilitation Act of 1973 prohibited discrimination of an otherwise qualified person from receiving benefits from or participating in any program or activity receiving federal funding. Discrimination includes any measurement of achievement that does not allow accommodation for the particular disability. Since virtually all colleges and universities and hospitals receive some type of federal funding, most resident physicians would have been included in Section 504. Regardless, the ADA extended this civil rights guarantee to all persons with disabilities in the private and public sector, regardless of funding source. According to the ADA, students and employees of hospitals, universities, and medical schools should have access to “reasonable accommodations” for their disability; these reasonable accommodations must include appropriate access to examinations and courses. In addition, evaluation and testing should reflect the actual fund of knowledge rather than any limits imposed by the disability (20). There is a consensus that the ADA requires that medical schools provide reasonable accommodations to residents as long as the accommodations do not cause undue burden on the institution and do not result in a fundamental alteration of the institution’s program.

Because residents occupy a dual role as employees of a hospital/institution and as students in that they are in training and under the supervision of residency programs, they potentially could be in a position that prevents them from accessing appropriate advocacy for their rights provided for under the ADA. As employees, they might need to appeal to a hospital to allow accommodations in order to function adequately in their role as house officers employees for that particular institution. As students, they would need access to academic accommodations from a residency program so that the measurement of their fund of clinical and/or academic knowledge is reflective of their actual grasp of the material. A clear policy in place would allow a vehicle for residents to access appropriate accommodations.

In 1999, the National Labor Relations Board addressed the dual role issue from a different perspective (21). Previous decisions in 1976 and 1977 had held that resident physicians were not covered under the National Labor Relations Act. The 1999 decision reversed the decisions of 1976 and 1977 and declared that resident physicians should be classified as “employees” and, as such, should have the right to form labor unions and to bargain collectively. However, the ACGME (22) made a clear statement that “residents are first and foremost students, rather than employees, and all accreditation and activities reflect this distinction.” The ACGME further stated that “residents need to be protected as students with respect to their educational environment and clinical settings in which they learn.” If the ACGME considers residents first and foremost students in regard to collective bargaining, it would seem reasonable that they should have access to the same disability accommodations as students as well.

It is important that a hospital and/or a psychiatry residency program institute accommodations that allow resident physicians to function at an acceptable level but do not sacrifice the quality of care given to patients. Ideally, determination of the appropriate type of accommodation should be a collaborative process between the resident, the designated individual in the training program, and the health care provider treating the resident (23). With the necessary documentation completed, the resident and the training director should meet to discuss the resident’s needs either in general or in response to a specific situation. The report from the practitioner supporting the diagnosis should also include recommendations for addressing the disability, including the necessity and reasonableness of the accommodations being requested (24). Though the treating clinician’s input is critical to the process, the ultimate determination should be made by the program official. The accommodation should be specific to the individual resident (23) and not dependent on accommodations that others have had put in place. The type of accommodation needed by one resident with ADHD might be different than that needed by another resident, given that differences in symptom presentation are unique to the individual.

The outcomes of these situations are difficult to predict as little is known about the career trajectories of “high functioning” persons with ADHD. Literature on adaptive functioning of ADHD children followed into adulthood suggests lower educational performance and attainment, poor job performance, and a higher likelihood of being fired from a job. But the presence of comorbid conditions, such as affective and conduct/oppositional defiant disorders, and the degree of hyperactivity contribute to poor outcomes (25, 26). Given their level of educational achievement, psychiatry residents likely are not typical in terms of their functioning in many areas. They are likely to have made a number of compensatory adaptations that account for their success in attaining this level of academic achievement. However, those with ADHD may find that their previous coping skills may not be effective, particularly in a new situation with a demanding schedule and the possible separation from their support system (27). There are also unique challenges associated with postgraduate training in psychiatry for which medical school provides only an imperfect introduction. Trainees are expected to emerge from the residency having the skills necessary for independent clinical practice as psychiatrists. These abilities are in the process of being defined by a number of organizations under the umbrella of a set of core competencies (28) as well as the expectation of competency in five types of psychotherapy (29).

Thus, because of the lack of data on outcomes for this group, we can only speculate about what difficulties trainees who are entering psychiatry residency and have been diagnosed with ADHD might have in completing core competencies. For purposes of discussion, we consider three domains of functioning associated with ADHD that could have an impact on functioning within the residency: 1) executive functioning; 2) attention; and 3) affect regulation. In Appendix 1, we identify which of these domains might impede successful acquisition and/or demonstration of the general competencies, and consider accommodations in the form of environmental supports and self-management strategies (30) that might be needed within the residency program. Environmental supports include: 1) task management strategies, such as providing detailed instruction and templates for guiding task completion; 2) environmental modifications, such as filing systems, distraction-free environments for testing, learning, and patient care; and 3) self-management strategies involving the development of certain habits, such as frequent reorientation to task, pacing of workflow, and consolidation of memory (30).

Some institutions have explicit general guidelines in place for handling resident disabilities as they apply to the ADA. For example, the Medical College of Wisconsin Affiliated Hospitals has an institutional policy for house staff that outlines the procedures for residents who are disabled (31). The steps in the process include: 1) notification of the program director by the resident of the need for accommodation; 2) collaboration between the resident and the program director on the identification of the resident’s limitations and potential accommodations; 3) written notification of the request to the executive director by the program director; and 4) implementation of the accommodation (if determined to be reasonable and not to cause undue hardship) by the program director after consultation with the executive director (31). Although still subject to some degree of discretion on the part of the individuals involved, such clear procedures are proactive and make the process known to those who might need to request some type of an accommodation. Shomaker (32) notes that it is easier to address a resident physician request if existing policies already are in place instead of addressing individual situations on a case-by-case basis.

A crucial issue in the design of the accommodations policy is whether the residency training program considers only those accommodations suggested by the treating clinician or whether it specifies additional educational expectations that will require that all supervisors be aware of the disability status of each resident. Whether at the bedside or in the classroom, the teacher must be aware of the performance of the resident and must make sure that the work is completed in a competent and appropriate manner. Appropriate environmental modifications must be in place if there is demonstrated need. However, providing accommodations in the absence of requiring effective self-management could be enabling instead of accommodating. Providing accommodations in the absence of a demonstrated need or in the absence of a request for such accommodations could blur the boundary between the treating clinician and the clinician educator. Careful attention to maintaining respect for the integrity of the educational process and for the privacy and the confidentiality of the resident physician should be the first priorities of the residency program.

The right to confidentiality exists for residents regarding all aspects of the determination of disability status as well as during the accommodation process. For residents who choose to disclose a diagnosis of ADHD, the documentation of a diagnosis should be kept in a separate confidential record and not in a general personnel file (33). The only Equal Employment Opportunity Commission (EEOC) confidentiality exclusion (33) applies to situations for which residents with ADHD request accommodations in which supervisors must be given information relating to specific duties performed. However, EEOC guidelines state that those involved in supervision should only have medical information if “strictly necessary” (33).

In situations where implementation of accommodations might invite curiosity on the part of other residents, faculty, or employees, confidentiality must still be upheld. On a practical level, it will be difficult to actively conceal accommodations granted to residents. Obviously, the resident can disclose information if he or she chooses to do so, but neither the department nor the institution should make any disclosures regarding the diagnosis or accommodations. To disclose this information without resident consent would be a violation of EEOC guidelines (34).

With the increase of ADHD diagnoses in adults and the increase in requirements for evidence of “core competency” in resident psychiatrists by the ACGME, there likely will be an increase in requests for accommodations by residents. Section 504 and the ADA provide for reasonable accommodations as long as those accommodations do not cause undue hardship on the institution or fundamentally alter the curriculum requirements. Though residents are employees, the ACGME views them first and foremost as students. The right to accommodations for medical students is well established. It seems reasonable that the same accommodations available for medical students should be made available for resident physicians. Because of the difficulty ADHD students have in the traditional academic environment, there should be differentiation between tests of academic knowledge and of clinical core competency. Academic tests should reflect the extent of knowledge base and not the limits imposed by the disability. From a functional standpoint, appropriate accommodations should be allowed so that residents can perform their jobs and carry out their responsibilities.

However, these accommodations should not alter the requirement that they meet the standards of the program, nor should it waive the responsibility to demonstrate core competencies. The goal is that with appropriate treatment, the symptoms of the disorder would be managed effectively, so that with any needed accommodations in place, the resident could meet the competency requirements. It is possible, though, that even with treatment and accommodations in place, some residents might be unable to successfully complete their training. Though such a situation would be unfortunate, upholding the standards of the profession is of the utmost importance, and the inability to perform the tasks associated with the competencies might compromise the well-being and safety of patients.

On a practical level, residency programs should set up guidelines and procedures for accommodations that are made available to residents. The procedures for accommodations should be proactive and accessible but they should not blur the boundary between the treating clinician and the educational program. These guidelines should include: 1) a requirement for appropriate and current documentation of ADHD by an appropriate diagnostician according to DSM-IV criteria; 2) specific accommodations tailored to individual need with a rationale for each accommodation recommended; 3) education of faculty, staff, and residents regarding applicable confidentiality rules; 4) ongoing discussion with the training director so that any evaluative tool tests for the fund of knowledge and not for the limits of the disability; and 5) ongoing evaluation of accommodations to make sure that the alterations in assessment do not relax standards for demonstrating core competencies prior to graduation and certification.