The Impact of COVID-19 on Communication in the Health Care Setting for People With Disabilities

By Jason M. Rotoli, MD, Cullen Donelly, MD, and Richard Sapp, MD, MS, on behalf of the SAEM Academy for Diversity and Inclusion in Emergency Medicine

A critical feature of modern, evidencebased medicine is the importance of establishing a therapeutic alliance, including clear bidirectional communication, between the practitioner and the individual. With proper communication, a therapeutic alliance can be built allowing for shared decision-making; however, this requires both the patient and practitioner to understand each other’s verbal communication, nonverbal language (body language, tone, facial expressions) and cultural nuances. Communication, however, is not without its barriers for many individuals within the disability community (~26% of the US population), which can affect an individual’s health and access to health care. In 2018, Stransky et al. found that individuals with disabilities affecting communication reported higher rates of “trouble finding a provider” for health care. Additionally, the same group of individuals were found to have higher rates of emergency department (ED) use, longer in-patient hospital stays, and more unmet care needs.

Impact of COVID-19 on Communication in the Disability Community

Communication in the health care system was stifled in the disability community in many ways during the COVID-19 pandemic. Information regarding the pandemic has been delayed, incomplete, or inaccessible to those with hearing loss or low vision. A study also found that there were limited exceptions for visitation policies allowing individuals with disabilities to have a member of their support team present, who is often critical to communication. Among all study sites, only 39% of hospitals reported exceptions for persons with cognitive impairment and 33% had exceptions for persons with physical impairment. Sites with EDspecific policies reported even fewer exceptions for patients with cognitive impairment (29%) or with physical impairments (24%).

With the advent of mask use during COVID-19, difficulties surrounding communication in the emergency department and health care system have been exacerbated. Individuals who rely on visual language, facial expression, and/or lip reading to aid in comprehension have lost that ability with the use of masks. While some patients have access to masks with clear shields/ windows allowing for parts of the face and mouth to be seen while speaking, these may not be widely available and may still be less than ideal (e.g., fogging up, incorrect mask size/fit, poor visibility/ quality).

Due to COVID-19 and post-COVID-19 hospital and ED overcrowding, patients are often boarding in alternative treatment areas (such as hallway chairs/beds), on hospital floors, and in EDs. In these areas, there is increased background noise, a lack of privacy, and overall increased distractions that perpetuate suboptimal communication between patients and their providers. Moreland et al. studied health care changes in the face of COVID-19 and reported that hospitals now face challenging communicative environments due to noisy equipment alarms, hurried health care teams spending less time with patients, and personal protective equipment (PPE) use that obstructs faces and muffles sounds. Additionally, these alternate treatment areas can be challenging to navigate for people with low vision or blindness and people who use a wheelchair for mobility.

The result of these communication barriers is still being investigated; however, people in impoverished socioeconomic classes and who have more chronic health conditions tend to have more severe disease and death in the setting of the pandemic. Although speculative, logic would suggest the disease burden and death toll to be higher in the disability community.

Tips for Improved Communication and Care

While 26% of Americans have disabilities, it was found that only 4.6%% of medical students disclose disabilities or request accommodations and current physicians with disabilities only represent only 3.1% of the workforce. Similar to other racial and ethnic minority groups, people with disabilities are more likely to be able to communicate with, relate to, and provide comfort to those with whom they can identify. This is a strong argument for further diversifying our health care workforce to include people with disabilities.

The most meaningful and impactful learning experiences in medicine come from learning from patients’ first-hand experiences and the impact it has on their lives; yet, in 2017 only 52% of medical schools reported having disability awareness training programs. Of those schools, only 10% had individuals with disabilities involved in the training program creation. Recent research shows that when medical students do receive training on disability, especially when this training is informed by individuals with disabilities, they report greater awareness of issues affecting individuals with disabilities and are able to understand disability through both biomedical and social models. For example, at the University of Rochester School of Medicine and Dentistry, a yearly experience called “Deaf Strong Hospital” is held where medical students participate in a role-reversal exercise during which they are hearing patients in a hospital where all the providers are deaf American Sign Language (ASL) users. In this situation, the students are encouraged to use different modes of communication (gesturing and other visual communication tools) and receive a first-hand view of health care through the lens of deaf individuals. In order to improve education on care of those with disabilities, undergraduate medical education should include more experiential activities related to care for the disability community. These experiences enhance development of alternative modes of communication, improve cultural awareness, and allow development of empathy and improved patient-provider rapport.

Additionally, medical school graduation requirements may also be modified to be more inclusive and meet the educational needs of the learner (with or without a disability). For example, modifying required competencies for the obstetrics clerkship (from completing the delivery of a baby to assisting in a delivery) may provide the necessary education if the student does not intend to pursue obstetrics. Another example is the requirement to perform cardiopulmonary resuscitation (CPR). The ability to perform CPR is often a barrier for applicants with disabilities; however, some programs’ requirements now state that applicants must be able to direct or perform CPR, which is more inclusive, provides the same education, and may better meet the needs of the student, thus changing these technical standards. These small adjustments to competencies allow students with physical disabilities (including those with chronic illnesses), who may otherwise be deemed

“unqualified,” to meet the requirements of their program and increase the disability community presence within physician workforce leading to the aforementioned benefits.

Flexible communication strategies including visual communication (body language, gesturing, writing/ text when feasible, qualified ASL interpreters) and communication technology (tablets, communication boards, communication access realtime translation [CART], etc.) can also increase the information exchange during a patient encounter. Additionally, flexible institutional policies allowing health care/support team members to accompany a patient with a disability during their visit may also enhance communication, information exchange, and access to more equitable care.

Conclusion

With existing communication barriers for patients with disabilities, conveying accurate and accessible health care and health information is a critical responsibility of health care practitioners to minimize misinformation and improve outcomes. While the health care system continues to deal with overcrowding and a thinly stretched workforce, steps must be taken to provide care for individuals with disabilities in the pursuit of positive health outcomes and improved access to their providers.

About The Authors

Dr. Rotoli is associate residency director, Department of Emergency Medicine and director, Deaf Health Pathways, at the University of Rochester Medical Center.

Dr. Donelly is an emergency medicine resident at the University of Rochester '25

Dr. Sapp is a second-year resident in the Harvard Affiliated Emergency Medicine Residency (MGH/BWH) who is passionate about improving health care for individuals with disabilities.

@SappMD