Home » United States case: Hartman v National Board of Medical Examiners (NBME)

United States case: Hartman v National Board of Medical Examiners (NBME)

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Last updated 17th May 2010 (part update 27th September 2019).

United States District Court for the Eastern District of Pennsylvania, 2010.

A medical student in the United States was granted a preliminary injunction allowing him to use a text-to-speech device in a medical exam, under the Americans with Disabilities Act (ADA). As at mid-May 2010 the decision was being appealed.

Facts and decision

A medical student with a ‘profound’ stammer was taking a Clinical Skills examination within the United States Medical Licensing Examination. The examination involved person to person encounters, and a few telephone encounters, with people acting as patients.

A US court granted a preliminary injunction against NBME allowing

  • the use of a text-to-speech device,
  • double time for each patient encounter, and
  • replacement of the telephone patient encounters with in-person encounters.

This was by way of ‘accomodation’, the US equivalent of reasonable adjustments. The latter two adjustments were agreed by NBME, but the text-to-speech device was not. The student wanted to use text-to-speech to supplement his ‘normal’ speech, as a back-up when he had a long block. The student used the text-to-speech device from time to time during his testimony in court.

The court gave NBME the right to require that the student also take the exam without a text-to-speech device, and that the scores of both exams be produced together with an explanation.

The student intended to enter pathology, which would involve marginal or no contact with patients. It is not evident though that this was important to the court’s decision.

As at mid-May 2010, the decision was being appealed by NBME. Also, this was not a full trial to finally determine rights under the ADA – though to get a preliminary injunction the student had to show amongst other things that he had a reasonable probability of success on the merits.

From the U.S. District Court’s judgment:

“…The use of a text-to-speech device is a reasonable accommodation so long as it does not preclude assessment of the particular skills the examination purports to measure, thereby fundamentally altering the examination. “The use of the text-to-speech device does not interfere with the ability of the NBME to score Hartman’s performance on the examination. The use of the device is merely an aid to, and not a replacement of, his normal speaking voice, which the examiners can still grade for the Spoken English Proficiency section of the examination. Hartman demonstrated during his testimony that he can use the device in a manner that ameliorates his most severe blocks or speech disfluencies but does not replace his normal speech. During his testimony, much of his verbal communication was through his spoken voice rather than the text-to-speech device. Hartman spoke in his own voice clearly and articulately. Intermittent use of the text-to-speech device will not hinder the standardized patients’ ability to grade how and with what skill Hartman can speak in the English language…”

My comment

In the UK, text-to-speech has been considered by tribunals as a possible reasonable adjustment in job interviews and presentations. As discussed in the StutterTalk interview, text-to-speech will probably be appropriate only for a fairly small number of people who stammer – the important point is to allow adjustments appropriate to the particular person.

This is not a UK case. However, the US test for accommodation in this context sounds roughly similar to that in Great Britain for reasonable adjustments. It seems that what is reasonable will depend on what competence standard is being tested, and the court considered use of text-to-speech to be consistent with what was being tested here.

I don’t know about the US, but in the UK there is also scope under the Equality Act 2010 to challenge whether a competence standard being tested is itself ‘justified’. The US case above may be of some interest in addressing whether a UK competence standard is justified as a proportionate means of achieving a legitimate aim. Even before the District Court decision, the NBME had evidently conceded that the student could have double time for each patient encounter, and that telephone patient encounters could be replaced with in-person encounters. Practice of non-UK examiners in allowing adjustments may make it harder for equivalent bodies in the UK to argue that competence standards inconsistent with such adjustments are a proportionate means of achieving a legitimate aim.

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