Cheri Blauwet, MD, of the Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation Hospital and Brigham and Women’s Hospital, is a board-certified physiatrist who is also a Paralympic gold medalist in wheelchair racing. As a person with spinal cord injury, she has used her personal experiences in healthcare and medical background to advocate for greater health equity for people with disabilities. This month, Dr. Blauwet and others published a commentary in The Lancet Oncology regarding the prevalence of ableism in oncological care. In this Q&A, Dr. Blauwet discusses her motivations for pursing this work and her plans for dismantling the existing obstacles.
Blauwet: My interest regarding the impact of ableism on the healthcare that we as clinicians provide and the health outcomes that we see is both personal and professional. Professionally, I am the chief medical officer at Spaulding and my clinical training is focused on enhancing function for people with disabilities. As a result, I am responsible for all the quality and care that our clinicians provide, and it’s my duty to reduce bias and improve health equity for this population. Personally, I have experienced a spinal cord injury and am a wheelchair user myself. I have experienced the healthcare system extensively throughout my life, and so I am aware of the effect that ableism can have on care. I also understand how unfair it is when providers treat patients differently because of their disability status, and so I have developed a deep personal passion for this type of work.
Blauwet: One prominent example concerns the decision to treat cancer patients with antineoplastic drugs, such as chemotherapy. Doctors calculate a rating based on performance measures that can indicate whether a patient would be able to tolerate what can be a difficult treatment course. Using a wheelchair results in a lower rating.
Unfortunately, such current performance measures for people who use wheelchairs are outdated and inherently ableist. Healthcare services have evolved alongside society, and what it means to be a wheelchair user today is much different than what it was in 1950. It no longer makes sense to base a treatment decision on if someone is a wheelchair user or not, as legislation has moved forward the lives of people with disabilities and allowed many wheelchair users to live very full and healthy lives.
Recognition and screening are also important in oncology. Both cognitive biases and structural ableism can have a negative impact on access to basic cancer screening and diagnostics. For example, getting a mammogram if you cannot stand can be difficult. For a clinician, if they are not aware of their cognitive biases or have not heard of the concept of ableism, this can unconsciously affect how they give treatment for persons with disabilities. Another example is the unconscious bias that someone with a disability is not sexually active, and so in that scenario, a physician may be less likely to screen a patient for sexually transmitted illnesses that may increase the risk for certain kinds of cancers.
Blauwet: In our new paper, we make several recommendations including improving outreach, funding, and data collection for cancer-care and cancer research organizations. But one piece that I would like to especially highlight is the intent to incorporate ableism and disability awareness into clinical training. Whether you’re a medical student, a resident, a fellow or a faculty member, integrating this understanding into the delivery of health care is vital.
We as a medical community have to view ableist tendencies in the same light as prejudiced or sexist stigmas and biases, and attempt to eliminate them from healthcare delivery, particularly within oncology. The world is evolving and it is important for medical treatment to advance as well.
Blauwet: This will have to be a team effort, where everyone works together to create lasting change. I think that we need multiple stakeholders, including leaders in oncology care to make national policy recommendations. This also encompasses physiatrists like me, and requires us to understand how all aspects of the cancer journey impact function. We should be thinking proactively about how the fields of physiatry and oncology can work together to optimize function throughout the continuum of oncology care including diagnosis, treatment, recovery and long-term health impact. Policy-wise, health service researchers and health policy experts should legislate methods for reducing biases. We are seeing this in real-time as just recently, the U.S. Department of Health and Human Services has proposed an update to strengthen the Americans with Disabilities Act.
One example where this could make an impact is with high exam tables at an OB-GYN clinic. Having a policy that ensures at least one table is able to accommodate people in wheelchairs will allow doctors to more easily perform pap smears and is a specific case where policy change can positively impact access to care.
Blauwet: As a physician, it’s important for me to consider how I can use my voice to enact change. For oncologists and healthcare leaders, advocating for both professional societies and leaders within the specialty to consider whether ableism exists in their treatment is paramount. This raises awareness, and in that same vein, is complemented by the publishing of papers, with research helping us to better understand the data that is related to ableism in oncology care.
Within every specialty of medicine, ableism can present itself. Making physicians aware of how ableism could be prevalent in their daily work is important. Providers in all medical specialties should talk to experts in these patient populations and work towards implementing the best practices for our patients, particularly for those fighting cancer.