Race and Disability Characteristics and Accommodation Disparities on the USMLE Step 1

Importance: Ensuring access to accommodations on high-stakes examinations is crucial for ensuring equal opportunity for medical students with disabilities (MSWD). Objective: To examine the associations between gender, race and ethnicity, disability type, timing of disability diagnosis, and access to specialized disability resource professionals (DRPs) with accommodation requests and approvals on the US Medical Licensing Examination (USMLE) Step 1. Design, Setting, and Participants: A cross-sectional study of MSWD who graduated between 2020 and 2023 was conducted across 9 US MD-granting medical schools. Variables included deidentified student data (ie, gender, race and ethnicity, disability type, and timing of diagnosis, either before or after matriculation) and presence of specialized DRPs. Exposure: Diagnosis of a disability. Main Outcomes and Measures: The primary outcome was USMLE Step 1 accommodation request and approval. χ2, Fisher exact, and post hoc pairwise tests were used to assess the associations between gender, race and ethnicity, disability type, timing of diagnosis, presence of specialized DRPs, and accommodation requests and approval. Results: Among 295 MSWD in the cohort (189 female [64%]), 41 (15%) identified as Asian, 162 (59%) as White, and 70 (26%) as underrepresented in medicine (URiM; ie, American Indian, Alaska Native, Black or African American, Hispanic, or Native Hawaiian or Pacific Islander). One hundred five students (36%) reported a psychological disability, 167 (58%) received a diagnosis before medical school matriculation, and 120 (41%) requested Step 1 accommodations. A higher proportion of White students requested Step 1 accommodations than Asian students (74 White students [46%] compared with 8 Asian students [20%]). No difference in Step 1 accommodation request rate was found for URiM students compared with White students. Compared with medical students with psychological disability (31 students [30%]), a higher proportion of students with attention-deficit/hyperactivity disorder (36 students [50%]) and chronic health conditions (27 students [53%]) requested Step 1 accommodations. A higher proportion of students who received a diagnosis before medical school (88 students [53%]) requested Step 1 accommodations compared with those who received a diagnosis after medical school matriculation (30 students [25%]). Among the 97 students with known Step 1 accommodation approval status, 67 (69%) received accommodations. Step 1 accommodation approval rates were lowest for medical students with psychological disabilities (14 students [52%]) and attention-deficit/hyperactivity disorder (13 students [52%]) and those who received a diagnosis after matriculation (9 students [43%]). MSWD in schools with specialized DRP support had higher approval rates for Step 1 accommodation requests than MSWD in schools without specialized DRPs (49 students [78%] vs 18 students [53%]). Conclusions and Relevance: In this cross-sectional study of MSWDs, Asian MSWDs had lower USMLE Step 1 accommodation request rates. Students with psychological disabilities and those who received a diagnosis after matriculation had lower request and approval rates. The presence of specialized DRPs was associated with higher accommodation approval rate. Addressing disparities in USMLE Step 1 accommodations is critical for promoting equity and fostering a more representative health care workforce.