Medical Excuse Policy Time for a new prescription? ACHA June 4, 2010

1. Medical Excuse PolicyTime for a new prescription?ACHA June 4, 2010 Janet Corson-Rikert, MD Cornell John Kolligian, PhD Princeton Bill Purdy, MD Duke

2. Medical Excuse Policy Introductions The Game Player perspectives Issues / problems Three institutional approaches Conversation with the audience Potential next steps

3. Cornell UniversityIthaca, New York • 21,000 students, 13,000 undergraduate • Slightly < 50% of undergrads live on campus • Seven undergraduate colleges with separate admissions, policies and procedures • No university-wide honor code • UHS reports to VP Student and Academic Services

4. Duke UniversityDurham, North Carolina • 13,000 students, 6500 undergraduate • Freshmen through juniors live on campus • Two undergraduate colleges • Honor code • SHS has dual report to Dept of Pediatrics and Student Affairs

5. Princeton UniversityPrinceton, New Jersey • 7500 students, 5000 undergraduate • All students live on campus • Two undergraduate colleges, consistent policies/procedures • Honor code focuses on in-class exams and written work • UHS reports to Vice President for Campus Life

6. What is the game? Jumping Through the Hoops, as played at Duke Christmas, W., Journal of American College Health, Vol. 46, 1998

7. What’s the problem? • Each college / university culture is unique • Game varies, but in all • SHS plays an unwanted and inappropriate role • goal that is not accomplished • Each player has a different perspective • Faculty, deans, students, SHS

8. Faculty perspective • Students use excuses to manipulate / gain advantage • Fabricated excuses create • Unfairness • More work for faculty • Medical excuses especially difficult • Not qualified to judge veracity

9. Dean’s perspective Need to be involved to administer process Take burden off individual faculty members Able to maintain objectivity In a position to identify patterns of abuse

10. Student perspective • Students with legitimate illness • Feel implicit distrust from faculty • May be coerced into sharing health records • Are ‘caught in the middle’ • Students who are manipulating the system • Learn that it’s easy to dupe providers • Are rewarded for creative deception • Students not using the system at all • May be disadvantaged

11. SHS perspective • Difficult to confirm legitimacy of excuses • After the fact • If no objective tests • When test results don’t correlate with disability • Providers are patient advocates • Unlikely to question history • Should not facilitate use of faculty power/authority to pressure students to share private information

12. SHS perspective • Fabricated history contaminates • Medical record • Relationship with provider • Displace medically appropriate visits • Entire process adds no value • Records same story as would have been provided to faculty member

13. Why care about this issue • Implications of this issue on student development • Emerging sense of self, authenticity, and integrity • Forging new relationships with important others • Identifying with institutional values and aspirations

14. Implications for Student Development • Fabricated illness • Reinforces student dishonesty, and promotes a system that sustains untruths • Injects disingenuousness, even disrespect, into the health care relationship • Complicates developing identities and civic values

15. Implications for Student Development • Legitimate illness • Implies mistrust, risks character insult, undermining faculty contacts • Creates pressure to disclose private information, tainting health-related contacts • Discourages independence and mature reliance by promoting such contacts

16. Mental Health-Related Excuses • Complications of excuses sought for psychological reasons • Stigma about mental health • Burden of invisible illnesses, and differences in excuse credibility • Role of physical and behavioral symptoms

17. Summary of Concerns • The medical excuse process • Disrespects students and right to privacy • Lowers expectations for adult behavior and citizenship • Creates a formal system for sustaining dishonesty • Creates burden for health services staff • Teaches inappropriate use of health care • Replaces more effective approaches to addressing academic integrity

18. Institutional approaches • Compromise through a verification of visit approach (e.g., Princeton) • Appeal to honor code and institute a new process (e.g., Duke) • Get out of the business (e.g., Cornell)

19. Princeton Experience For deans and faculty—notes generally seen as essential, honor code as inapplicable Excuse notes modified to verification of visit notes in 2004 Discontent at UHS’s suspension of notes in fall 2009, as per CDC H1N1 guidelines

21. Duke Experience

24. Duke Student Health The student listed below came into Student Health today and asked us to notify his/her dean: Name:_____________________________________________________ Duke Unique #______________________________________________ Date: December _________, 2009 Signed: ________________________________________________

25. Notification of a Student Visit to a Health Care Provider During the Final Exam Period FOR THE STUDENT: Only your academic dean may authorize an absence from a final exam. Before evaluating your request to be excused from a final exam because of incapacitating illness, your academic dean requests that you be seen by a health care provider. Please initial and sign this form as indicated below and obtain the signature of a health care provider. You may either return this form to your academic dean’s office or ask your health care provider to fax this form to the number indicated below. ____ (Student initials). I’ve received this form from my academic dean because I’ve stated that I have an incapacitating illness that renders me unable to take my final exam. ____(Student initials). I understand that for my own safety, I must see a private health care provider or someone in Duke Student Health or CAPS as soon as possible. ____(Student initials). I give permission to my health care provider to communicate information to my academic dean about my health care visit as it pertains to the dean’s decision to authorize an absence from a final exam.

26. ___ (Student initials). I am aware that in submitting this form, I am bound by the Duke Community Standard. I pledge that I will not obtain information of any kind that will provide me with an unfair advantage over other students taking the final exam. Student Signature:____________________________ Date: __________________ FOR THE HEALTH CARE PROVIDER: This student was seen in (please circle): a) Student Health b) CAPS c) Private Office d) Other on (date) ______________ by (please print name) ____________________________________. If you need to contact me, the best way to reach me is by calling _________________________or sending an e-mail to ___________________. Health Care Provider Signature:_______________________ Date: ___________ PLEASE FAX THIS FORM WITHIN 24 HOURS TO 919-684-4515 (a different form will be made for the West Camps deans with their fax number)

27. The Duke Community Standard Duke University is a community dedicated to scholarship, leadership, and service and to the principles of honesty, fairness, respect, and accountability. Citizens of this community commit to reflect upon and uphold these principles in all academic and non-academic endeavors, and to protect and promote a culture of integrity. To uphold the Duke Community Standard: I will not lie, cheat, or steal in academic endeavors; I will conduct myself honorably in all my endeavors; and I will act if the Standard is compromised.

28. Cornell Experience

29. Cornell Experience • 2004 • Dean of the Faculty • Executive Committee Campus Health • University Assembly discussion • Derailed by discussion of honor code • 2009 • Created H1N1-related policy, then generalized • Planned academically-based enforcement

30. Faculty Handbook The university expects that students will be honest with their professors about routine illnesses, injuries, and mental health problems that may lead to missed classes, labs, studios, exams, or deadlines. Academic advising staff and associate deans are available to provide assistance to students or faculty members who have concerns about attendance issues. See also the CU Health Excuse Policywww.gannett.cornell.edu/services/health-excuses.cfm

31. Serious, ongoing illness or injury When a student is hospitalized or has a serious illness or injury ― and with the student's consent ― Gannett will contact Cornell's Crisis Manager to coordinate communication with the student's college. To facilitate an academic accommodation, and at the student's request and with the student's permission, Gannett will communicate further with the college's academic advising office and/or Student Disability Services.

32. Recommendations • Engage clinicians on common approach • Identify academic partner(s) • Review practical and philosophical concerns • Build off honor code if present, or institute as free-standing policy if not • Aim for co-ownership • Get students involved • Communicate a simple policy through academic channels • Plan ahead for enforcement

34. Other recommendations, approaches, and steps Have your institutions had success with similar or different approaches? Would it be helpful to have an ACHA position paper on this topic?

35. Web Links • Cornell http://www.gannett.cornell.edu • Duke http://www.studentaffairs.duke.edu/studenthealth • Princeton http://www.princeton.edu/uhs