Examination of Persons with Disabilities

I. Commitment to a Fair and Equitable Exam Experience for All Candidates

It is the commitment and policy of the American Board of Surgery (ABS) to fully comply with the Americans with Disabilities Act of 1990 (the ADA), all amendments thereto and any accompanying applicable regulations. Therefore, consistent with and in accordance with the ADA, the ABS endeavors to administer its examinations, where feasible, in a manner that best ensures equal access for individuals with documented qualifying disabilities, medical conditions, or who are lactating or pregnant, and who demonstrate and request a need for accommodation(s), provided that the requested accommodation is reasonable, not unduly burdensome, and does not fundamentally alter the measurement of the skills or knowledge being assessed.

The ADA defines a person with a disability as someone with a physical or mental impairment that substantially limits one or more major life activities such as walking, seeing, hearing, or learning. The ABS recognizes that surgeons with disabilities may wish to gain access to the ABS’s initial certification activities and will attempt to make reasonable accommodations for candidates with verified disabilities and other conditions who follow these policies and procedures.

II. Purpose of Examination Accommodations

The purpose of an examination accommodation is to provide equal access to obtaining ABS certification, not certification itself. It is important to note that the objectives of the written and oral certification examinations are different: the written examination tests the examinee’s fund of cognitive information relevant to surgery; the oral examination tests the ability to utilize that knowledge in time-sensitive technical and judgmental situations related to the proper management of a broad spectrum of surgical conditions. The essential nature of the oral examination is to evaluate a candidate’s ability to promptly and efficiently address clinical situations and make treatment decisions under real-world conditions. Numerous situations in surgery, both in the diagnostic arena with emergencies and in the operating room when encountering unexpected events, require rapid decision making and the analytical skill to quickly evaluate alternatives. The oral examination is designed to test a candidate’s ability to make similar decisions under similar time constraints.

As such, no candidate will be excused from either the written or oral examination for initial certification. Further, no candidate will be granted an accommodation that would compromise either examination’s ability to accurately assess the skills and knowledge it is designed to measure. Similarly, no auxiliary aid or service will be provided that would fundamentally alter either examination or would result in an undue burden to ABS.

The ABS allows appropriate accommodations in order to best ensure that the results of the examination reflect each individual’s proficiency in the content areas, rather than reflecting an individual’s impaired sensory, manual, cognitive, or psychological skills (except where those skills are the factors that the examination purports to measure). While the intent of the use of an examination accommodation is to enable an individual to demonstrate their proficiency in the knowledge being assessed, granted, or approved, accommodations are not a guarantee of improved performance, test completion, a passing score, or ABS certification.

III. Procedure for Requesting an Accommodation

An applicant who wishes to request modification of the ABS’s examination procedures on the basis of disabilities or learning differences should complete the following steps:

1. Review the applicable documentation guidelines included in this policy and share them with the professional who will be preparing the accompanying documentation.
2. Complete the Questionnaire & Exam Accommodation Request Form For Candidates With Disabilities.
3. Upload documentation according to this policy’s guidelines of the disability and the need for accommodation with the questionnaire and examination application via the ABS portal.
   Applicants must ensure that they are submitting complete documentation as required by this policy. Incomplete documentation will delay processing of the request.
4. The questionnaire and accompanying documentation of disability or learning differences must be received no later than April 15. No requests for test accommodations after this date will be accepted.

IV. General Documentation Guidelines for All Disabilities

The following guidelines will assist applicants in documenting a need for accommodations based on an impairment that substantially limits one or more major life activities. The individual requesting accommodations must personally initiate a written request for specific test accommodations. Requests by a third party, such as an evaluator, cannot be honored.

To request accommodations, please submit the following:

1. A completed questionnaire.
2. A detailed, comprehensive written report from a qualified professional describing your disability and its severity and explaining the need for the requested accommodations. The report should:
   • State a specific diagnosis of the disability using professionally recognized nomenclature, g., American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV); International Classification of Diseases (ICD).
   • Be current. Because the provision of accommodations is based on the current impact of the disability on the testing activity, the evaluation should have been conducted no more than five years prior to the request for accommodations.
   • Clearly describe the specific diagnostic criteria and name the diagnostic tests used, including date(s) of evaluation, list specific test results and provide a detailed interpretation of the test results in support of the diagnosis. Be sure to include all relevant educational, developmental and medical history.
   • Give a detailed description of the applicant’s current functional limitations due to the diagnosed disability and an explanation of how the diagnostic test results relate to the identified functional limitations. Fully describe the impact of the disability on physical, perceptual and cognitive
   • Recommend specific accommodations including assistive. Provide a detailed explanation of why these accommodations or devices are needed and how they will reduce the impact of the identified functional limitations on the specific examination (oral or written) for which they are requested.
   • Provide contact information and credentials of the professional evaluator that qualify him/her to make the diagnosis, including information about professional license or certification and specialization in the area of the diagnosis. The dated report must be written on the professional evaluator’s letterhead and clearly indicate the name, address, telephone number and qualifications of the professional. The evaluator should present evidence of comprehensive training and direct experience in the diagnosis and treatment of adults in the specific area of disability.
3. If no prior accommodations have been provided, the qualified professional expert should include a detailed explanation as to why no accommodations were given in the past and why accommodations are needed

Please review the following sections for more detailed documentation requirements pertaining to specific types of disabilities.

V. Documentation Guidelines for Learning and Cognitive Disabilities

Many learning disabilities are not readily observable, and the definition and etiological criteria used for diagnosing such impairments do not necessarily have consensual validation in the medical and psychological communities.

The ABS defines a “learning disability” as a specifically diagnosed learning disorder, based on standard nomenclature and diagnostic criteria, impacting one or mental abilities such as using language, processing information and learning, that may manifest in the ability to read, spell, write, and perform mathematical operations.

Note: Test anxiety, English as a second language (in and of itself), slow reading without an identified underlying cognitive deficit, or failure to achieve a desired academic outcome are not learning disabilities, and therefore, are not covered under the American with Disabilities Act (ADA). Requests for accommodations based on the above will not be considered or honored.

A. Documentation Process

The following provides additional information for applicants submitting a request for accommodations based on a learning disability or other cognitive impairment:

1. The evaluation must be conducted by a qualified professional. The diagnostician conducting the evaluation must have comprehensive training in the field of learning disabilities and must have comprehensive training and direct experience in working with an adult population.
2. All testing must be current. The determination of whether an individual is significantly limited in functioning according to Americans with Disabilities Act (ADA) criteria is based on assessment of the current impact of the impairment. Therefore, the tests conducted as part of a comprehensive psychoeducational assessment should be no more than five years old. (See General Guidelines.) In addition, a developmental disorder such as a learning disability originates in childhood and, therefore, school history and other information which demonstrates a history of impaired functioning should also be provided. Wherever possible, actual school records, psychological reports and other objective historical information should be provided.
3. Documentation must be comprehensive. In addition to the applicant’s self-report, the report of assessment should include a comprehensive history-taking with relevant background information to support the diagnosis. The report should include:
   • description of the presenting problem(s);
   • a developmental history;
   • relevant academic history including results of prior standardized testing, school reports and notable trends in academic performance;
   • relevant family history, including primary language of the home and current level of fluency in English;
   • relevant medical and employment history; and
   • a differential diagnosis, exploring and ruling out possible alternative or co-existing mood, behavioral, neurological and/or personality disorders which may impact the individual’s learning.The psychoeducational or neuropsychological evaluation should include:
     • a comprehensive battery of tests;
     • a diagnosis based on a convergence of all test data, history and level of current functioning (NOTE: it is not acceptable to base a diagnosis on only one or two subtests); and
     • objective evidence of a substantial limitation to learning.
     • Additionally, tests must be appropriately normed for the age of the patient and must be administered in the designated standardized manner.

B. The Documentation Data

The psychoeducational or neuropsychological evaluation should include the following data:

1. Cognitive Functioning: A complete cognitive assessment is essential with all subtests and standard scores reported. Acceptable measures include but are not limited to: Wechsler Adult Intelligence Scale-III (WAIS-III); Woodcock Johnson Psychoeducational Battery-III: Tests of Cognitive Ability; Kaufman Adolescent and Adult Intelligence Test.
2. Academic Achievement: A comprehensive achievement battery with all subtests and standard scores is essential. The battery must include current levels of academic functioning in relevant areas such as reading (decoding and comprehension) and mathematics. Acceptable instruments include, but are not limited to, the Woodcock-Johnson Psychoeducational Battery – III: Tests of Achievement; The Scholastic Abilities Test for Adults (SATA); Woodcock Reading Mastery Tests-Revised. Specific achievement tests are useful instruments when administered under standardized conditions and when interpreted within the context of other diagnostic information. The Wide Range Achievement Test-3 (WRAT-3) and the Nelson-Denny Reading Test are not comprehensive diagnostic measures of achievement and therefore neither is acceptable if used as the sole measure of achievement.
3. Information Processing: Specific areas of information processing (e.g., short- and long-term memory, sequential memory, auditory and visual perception/processing, auditory and phonological awareness, processing speed, executive functioning, motor ability) must be assessed. Acceptable measures include, but are not limited to, the Detroit Tests of Learning Aptitude – Adult (DTLA-A), Wechsler Memory Scale-III (WMS-III), information from the Woodcock Johnson Psychoeducational Battery III: Tests of Cognitive Ability, as well as other relevant instruments that may be used to address these areas.
4. Other Assessment Measures: Other formal assessment measures or nonstandard measures and informal assessment procedures or observations may be integrated with the above instruments to help support a differential diagnosis or to disentangle the learning disability from co-existing neurological and/or psychiatric issues. In addition to standardized test batteries, nonstandardized measures and informal assessment procedures may be helpful in determining performance across a variety of domains.
   • Actual test scores must be provided (standard scores where available) as well as identification of norms used to interpret the data.
   • A differential diagnosis must be reviewed and various possible alternative causes for the identified academic problems should be ruled out. The evaluation should address key constructs underlying the concept of learning disabilities and provide clear and specific evidence of the information processing deficit(s) and how these deficits currently impair the individual’s ability to learn. No single test or subtest is a sufficient basis for a diagnosis. The differential diagnosis must demonstrate that:
     • Significant difficulties persist in the acquisition and use of listening, speaking, reading, writing or reasoning skills.
     • The problems being experienced are not primarily due to lack of exposure to the behaviors needed for academic learning or to an inadequate match between the individual’s ability and the instructional demands.

C. Diagnostic Rationale

It is essential that the evaluator integrate all information gathered in a well-developed clinical summary. The following elements must be included in the clinical summary:

1. Rationale for ruling out alternative explanations for the identified academic problems as a result of poor education, poor motivation and/or study skills, emotional problems, attentional problems, cultural or language differences or other reasons;
2. Indication of how patterns in cognitive ability, achievement and information processing are used to determine the presence of a learning disability;
3. Indication of the substantial limitation to learning presented by the learning disability and the degree to which it impacts the individual in the context of the Surgery examinations; and
4. Indication as to why specific accommodations are needed and how the effects of the specific disability are mediated by the recommended accommodation(s).

Problems such as test anxiety, English as a second language (in and of itself), slow reading without an identified underlying cognitive deficit, or failure to achieve a desired academic outcome are not learning disabilities and therefore are not covered under the Americans with Disabilities Act.

D. Rationale for Accommodations

The diagnostic report must include specific recommendations for accommodations and a detailed explanation as to why each accommodation is recommended. Recommendations must be tied to specific test results or clinical observations.

The documentation should include any record of prior accommodation or auxiliary aids, including any information about specific conditions under which the accommodations were used and whether or not they were effective. However, a prior history of accommodation, without demonstration of a current need, does not in and of itself warrant the provision of a like accommodation. If no prior accommodation(s) has been provided, the qualified professional expert should include a detailed explanation as to why no accommodation(s) was used in the past and why accommodation(s) is needed at this time.

VI. Documentation Guidelines for Attention-Deficit/Hyperactivity Disorder

A. The Documentation Process

The following provides additional information for applicants submitting a request for accommodations based on Attention-Deficit/Hyperactivity Disorder (ADHD).

1. The evaluation must be conducted by a qualified professional. The diagnostician conducting the evaluation must have comprehensive training in the field of adult Attention Deficit/Hyperactivity Disorder and must have comprehensive training and direct experience in working with an adult population.
2. All testing must be current. The determination of whether an individual is significantly limited in functioning according to Americans with Disabilities Act (ADA) criteria is based on assessment of the current impact of the impairment on the American Board of Surgery examination program.
3. Documentation must be comprehensive. Because ADHD by definition is first exhibited in childhood (although it may not have been formally diagnosed) and in more than one setting, objective, relevant, historical information is essential. Information verifying a chronic course of ADHD symptoms from childhood through adolescence to adulthood, such as educational transcripts, report cards, teacher comments, tutoring evaluations, job assessments and the like are necessary.
   • The evaluator must review and discuss DSM-IV diagnostic criteria for ADHD and describe the extent to which the patient meets these criteria. The report must include information about the specific symptoms exhibited and document that the patient meets criteria for long-standing history, impairment and pervasiveness.
   • A history of the individual’s presenting symptoms must be provided, including evidence of ongoing impulsive/hyperactive or inattentive behaviors (as specified in DSM-IV) that significantly impair functioning in two or more settings.

B. The Documentation Data

1. Historical Data: The information collected by the evaluator must consist of more than patient self-report. Information from third-party sources is critical in the diagnosis of adult ADHD. Information gathered in the diagnostic interview and reported in the evaluation should include, but not necessarily be limited to, the following:
   • History of presenting attentional symptoms, including evidence of ongoing impulsive/hyperactive or inattentive behavior that has significantly impaired functioning over time;
   • Developmental history;
   • Family history for presence of ADHD and other educational, learning, physical or psychological difficulties deemed relevant by the examiner;
   • Relevant medical and medication history, including the absence of a medical basis for the symptoms being evaluated;
   • Relevant psychosocial history and any relevant interventions;
   • A thorough academic history of elementary, secondary and postsecondary education;
   • Review of psychoeducational test reports to determine if a pattern of strengths or weaknesses is supportive of attention or learning problems;
   • Evidence of impairment in several life settings (home, school, work) and evidence that the disorder significantly restricts one or more major life activities.
   • Relevant employment history;
   • Description of current functional limitations relative to an educational setting including test taking that are presumably a direct result of the described problems with attention;
   • A discussion of the differential diagnosis, including alternative or co-existing mood, behavioral, neurological and/or personality disorders that may confound the diagnosis of ADHD; and
   • Exploration of possible alternative diagnoses that may mimic ADHD.
2. Relevant Assessment Batteries: A neuropsychological or psychoeducational assessment may be necessary in order to determine the individual’s pattern of strengths or weaknesses and to determine whether there are patterns supportive of attention problems. Test scores or subtest scores alone should not be used as the sole basis for the diagnostic decision. Scores from subtests on the Wechsler Adult Intelligence Scale – III (WAIS – III), memory functions tests, attention or tracking tests or continuous performance tests do not in and of themselves establish the presence or absence of ADHD. They may, however, be useful as one part of the process in developing clinical hypotheses. Checklists and/or surveys can serve to supplement the diagnostic profile but by themselves are not adequate for the diagnosis of ADHD. When testing is used, standard scores must be provided for all normed measures.
3. Identification of DSM-IV Criteria: A diagnostic report must include a review of the DSM-IV criteria for ADHD both currently and retrospectively and specify which symptoms are present (see DSM-IV for specific criteria). According to DSM-IV, “the essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity- impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” Other criteria include:
   • Symptoms of hyperactivity-impulsivity or inattention that cause impairment that were present in childhood.
   • Current symptoms that have been present for at least the past six months.
   • Impairment from the symptoms present in two or more settings (school, work, home).

C. Diagnostic Rationale

The report must include a specific diagnosis of ADHD based on the DSM-IV diagnostic criteria. Individuals who report problems with organization, test anxiety, memory and concentration only on a situational basis do not fit the diagnostic criteria for ADHD. Given that many individuals benefit from prescribed medications and therapies, a positive response to medication by itself is not supportive of a diagnosis, nor does the use of medication in and of itself either support or negate the need for accommodation.

It is essential that the evaluator integrate all information gathered in a well-developed clinical summary. The clinical summary must include:

1. Rationale for ruling out alternative explanations for inattentiveness, impulsivity, and/or hyperactivity as a result of psychological or medical disorders or non-cognitive factors;
2. Indication of how patterns of inattentiveness, impulsivity and/or hyperactivity across the life span and across settings are used to determine the presence of ADHD;
3. Description of the substantial limitation presented by ADHD and the degree to which it impacts the individual in the context for which accommodations are being requested (e.g., impact on the American Board of Surgery testing program); and
4. Explanation as to why specific accommodations are needed and how the effects of ADHD symptoms, as designated by the DSM-IV, are mediated by the accommodation(s).

D. Rationale for Accommodations

A detailed explanation must be provided as to why each accommodation is recommended and should be correlated with specific identified functional limitations.

The documentation should include any record of prior accommodation or auxiliary aids, including any information about specific conditions under which the accommodations were used and whether or not they were effective. However, a prior history of accommodation, without demonstration of a current need, does not in and of itself warrant the provision of a like accommodation. If no prior accommodation(s) has been provided, the qualified professional expert should include a detailed explanation as to why no accommodation(s) was used in the past and why accommodation(s) is needed at this time.

Because of the challenge of distinguishing ADHD from normal developmental patterns and behaviors of adults, including procrastination, disorganization, distractibility, restlessness, boredom, academic underachievement or failure, low self-esteem and chronic tardiness or inattendance, a multifaceted evaluation must address the intensity and frequency of the symptoms and whether these behaviors constitute an impairment in a major life activity.

If you have any questions about this policy or about the required form and/or documentation, please contact us.

UPDATED: March 2024