An Exploration and Comparison of the Worklife Experiences of Registered Nurses and Physicians with Permanent Physical and/or Sensory Disabilities

Authors

  • Leslie Neal-Boylan PhD CRRN APRN-BC FNP

Errata

This article is corrected by:

  1. Errata: Errata Volume 37, Issue 2, 94, Article first published online: 20 March 2012
  2. Errata: Errata Volume 37, Issue 2, 94, Article first published online: 20 March 2012

Abstract

Purpose

To examine the worklife experiences of physicians, to further the exploration of the worklife experiences of nurses with disabilities, and to discover how the two healthcare professions compare with each other with regard to these experiences.

Methods

This study employed the research tradition of interpretive naturalistic inquiry and used constant comparative analysis to collect and analyze the data.

Findings

Despite the cultural and educational differences between physicians and RNs, their experiences as healthcare professionals with self-identified permanent physical and/or sensory disabilities were very similar. The research team identified five core themes.

Conclusions

Healthcare professionals, including staff and administrators, need to make an effort to retain employees as turnover and predicted shortages are likely to jeopardize the current healthcare system.

Clinical relevance

Modifications can be made within both professions to support people with disabilities and to enable them to contribute to their professions using their abilities to think critically, solve problems, and care for patients safely.

So far, research regarding registered nurses (RNs) with disabilities has revealed that nurses with physical and/or sensory disabilities are leaving the profession or are at risk for leaving. To date, these studies and others have not yet determined how many nurses have disabilities or are working with disabilities (Dickson, 1993; Neal-Boylan & Guillett, 2008a; Trossman, 2003). The same information is lacking and/or inconsistent with regard to physicians (Corbet & Madorsky, 1991; El-Mallakh, 1985; Gautam & MacDonald, 2001; Martini, 1987; Nielsen, 2001; Wainapel, 1987a,b). However, it is likely that a significant number of physicians and nurses have disabilities and are working in their professions, because as of 2008, approximately 19% of adults reported having a disability (Bureau of Labor Statistics, 2011; Facts for Features, 2010).

An aging nurse workforce (Wray, Aspland, Gibson, Stimpson & Watson, 2009) and a predicted decline in practicing physicians (Association of American Medical Colleges, 2009) warrant the need to retain these healthcare professionals (Ferguson, Evan, Hajduk & Jones, 2009). The continuing quest to determine why healthcare professionals with physical and/or sensory disabilities leave their professions is necessary to prevent their exodus (Ferguson et al., 2009). This article describes a research study that was undertaken to explore the worklife experiences of physicians, to further the exploration of the worklife experiences of nurses with disabilities, and to discover how the two healthcare professions compare each other with regard to these experiences.

Research Questions

The study explored the following research questions:

  • What is it like to be a physician/registered nurse with a physical disability?
  • How does the work change, if at all, in light of the physical disability?
  • What barriers does the physical disability presentto the physician/RN in the workplace?
  • What facilitates the work of the physician/RN with a disability?
  • How does the physical disability influence career decisions of the physician/RN?
  • Does the disability jeopardize the ability of the physician/RN to practice medicine/nursing safely?
  • How do the experiences of RNs and physicians compare, with regard to having a physical disability?
  • What modifications could be made to the workplace or within the profession (for example: education, employment, recruitment) to enhance the ability of the physician/RN with a physical disability?

Background

Other exploratory studies regarding RNs with disabilities have concluded that nurses with physical and/or sensory disabilities have a tendency to leave the profession (Neal-Boylan, Fennie & Baldauf-Wagner, 2011; Neal-Boylan & Guillett, 2008a,b,c). This is partly due to a feeling of being pushed out because colleagues and administrators suspect that these nurses cannot perform safely or do not “pull their weight.” It is also partly due to a feeling by the nurses themselves that they will jeopardize patient safety if they stay. More often than not, there are no or inadequate attempts by healthcare agencies and facilities to retain RNs with disabilities by accommodating them or by moving them into positions that will benefit from their expertise and experience despite their disability.

There have also been anecdotal descriptions in the literature regarding the experiences of nurses with disabilities (Anonymous, 2003; Bemi, 2009; Weiss, 2005). This literature supports the research regarding the challenges that RNs with disabilities face in the workplace and their inclination to explore new career paths. Physicians seem to foster a culture of invincibility, so that admitting to having a disability may be seen as incongruent with being viewed as the ideal health care provider (Wainapel, 1999). The literature regarding physicians with disabilities has been largely anecdotal with some survey data (Allen & Devinsky, 2007; Anthony & Spalding, 1993; Currier, 1994; Lawn, 1989; Mercer, Dieppe & Chambers, 2003; Pone, 2003; Rabin, Rabin & Rabin, 1982; Steinberg, Iezzoni, Conill & Stineman, 2002; Stetten, 1981; Wainapel, 1987a,b; Webster, 1980) and mostly includes descriptions of personal experiences by physicians with disabilities.

Conceptual Framework

This study, as part of a larger program of research about nurses with disabilities, relied on the “Integrative Model of Health Care Working Conditions on Organizational Climate and Safety” (Stone et al., 2005). The model (Figure 1) suggests that leadership, organization, supervision, work design, group behavior, and quality emphasis influence outcomes for the healthcare worker and patient. Organizational climate and organizational culture have significant effects on healthcare worker and patient outcomes and are often changeable. A previous study of nurses with disabilities that used this model as a framework (Neal-Boylan et al., 2011) targeted the organizational climate with regard to workload. Whether the nurse considered the workload manageable or not seemed to influence whether the nurse had left the job or was at risk of leaving or not. The previous studies found that both organizational culture and climate with regard to the attitudes of leadership (administration) and colleagues (group behavior) influence how the nurse with disabilities feels about and experiences the job and the decision regarding whether to leave the job or not.

Figure 1.

An Integrative Model of the Relationships between Health Care Working Conditions and Organizational Climate and Safety (Stone et al. 2005)

Methodology

This study employed the research tradition of interpretive naturalistic inquiry and used constant comparative analysis to collect and analyze the data. The snowball technique as well as advertisements in newsletters, on list serves, and through professional organizations, was used to recruit participants. The research team sought to recruit licensed RNs and physicians who worked in a variety of settings and clinical specialties. Originally, recruitment was focused on Connecticut, but was later expanded to include participants from within the United States, as it was particularly difficult to recruit physicians with disabilities. Great effort was made to include healthcare professionals with a variety of physical and/or sensory disabilities.

For the purposes of this exploratory qualitative study, disability was defined as an alteration of an individual's capacity to meet occupational demands because of a chronic condition associated with a functional limitation (Cocchiarella & Andersson, 2001; http://www.who.int/topics/disaiblities/en/).

Participants who contacted the researchers or were contacted by the research team were asked to participate in an in-person or telephone audiotaped interview that lasted approximately 45 minutes. Digital recorders were used to audiotape the interviews. The Human Investigation Committee of the Yale School of Medicine approved the research protocol. All of the participants provided informed consent. One RN conducted all the nurse interviews and one physician (MD) conducted all the physician interviews. Each interviewer used the same unstructured interview guide (Figure 2). As interviews were transcribed verbatim and analyzed by the research team, the interviewers were asked to add certain questions to the succeeding interviews. Thus, constant comparative analysis occurred as data were collected and the team identified themes from the data. Interviewers reviewed the transcriptions to ensure accuracy prior to analysis by the research team.

Figure 2.

Interview guide

Data Analysis

Data collection ceased once data saturation was reached. An inductive qualitative approach was used to analyze the data concurrently with data collection. The constant comparative method (Strauss & Corbin, 1990) was used to analyze data. Between sets of interviews, the coding team (a subset of the research team) would gather to discuss the themes that they had derived independently. A coding structure was systematically developed as transcripts were coded line-by-line. When coding team members concurred on themes, these were then added to the emerging coding structure. As analysis continued, themes were grouped or discarded as they became more or less relevant to the data.

The coding team not only included the original researchers (including one physician and one RN) but also included one working RN and one working physician each with a self-identified disability. These team members added their personal perspectives to the analysis. The research team itself was diverse with regard to age, profession, healthcare work setting, and ethnicity.

Once the final coding structure was derived, an expert in the field of disability was asked to review the findings and suggested minor revisions, which were agreed upon by all members of the research team. The final summary of the findings was collated into a format for participant verification. All of the participants in the study were asked to comment on the participant verification summary. Both the physician and the RN participants read the same participant verification summary and none reported any need for revision or change to enhance accuracy.

Sample

A purposive sample of 10 RNs and 10 physicians with self-identified permanent physical and/or sensory disabilities were interviewed. Participants worked in acute and sub-acute hospitals, outpatient clinics and practices, academic healthcare centers, and in long-term care. Others were consultants. Only half of the nurses in the study were employed at the time of the study, whereas all the physicians were employed. This is consistent with previous research regarding nurses with disabilities, which demonstrated that these nurses tend to leave nursing because of the disability.

Most of the nurses were women (7), and most of the physicians were men (6). All of the patients ranged from 30 to 80 years of age. Both participant groups had a variety of musculoskeletal conditions, such as limb injury; neurologic conditions, such as multiple sclerosis; chronic conditions that resulted in disability, such as Systemic Lupus Erythematosus; and sensory impairments, both in vision and hearing. Participants had completed the entry-level training in their professions between 1 and 40 years prior to the study.

Findings

Despite the cultural and educational differences between physicians and RNs, their experiences as healthcare professionals with self-identified permanent physical and/or sensory disabilities were very similar. The research team identified five core themes as a result of the study:

  • Disability narrows and alters career choices and career trajectories.
  • It is a struggle to decide whether to disclose or discuss the disability in the workplace or not.
  • It is rare for physicians or nurses to request workplace accommodations. It is more likely for them to view patient safety as their own responsibility.
  • The organizational climate and culture regarding disability are reflected in the interactions nurses and physicians have with others in the workplace.
  • Physicians and nurses experience a broad range of emotion regarding their disability-related challenges in the workplace.

Career Choices and Trajectories

The nurses in the study had seemingly more flexibility about changing their career patterns than did the physicians. Physicians must choose a specialty early to focus on during their residency. One physician described making the decision while in his residency to go into psychiatry because of his disability.

Nurses receive the same basic education, although it varies slightly if the entry level into practice is an associate degree, diploma, or baccalaureate. Once the nurse has received the basic education, he/she is free to pursue various specialties, but may be expected to obtain certification in a particular area.

For both the physicians and nurses in the study, the timing of the onset of the disability was key to choosing the specialty area of practice. Those who already had the disability while in school tended to choose (or were encouraged to choose) areas of practice for which others felt they were best suited. This was truer for the physicians than for the nurses, as it can be difficult for nursing students to progress through nursing programs and meet clinical requirements if they have a physical disability (Carroll, 2004). Consequently, most of the nurses in this study, as in the previous studies of nurses, commented on their career choices since acquiring their disability after nursing school or since the disability had worsened enough to impact their nursing practice. Medical students are more likely, based on this study, to receive accommodation, but are strongly encouraged to seek specialty areas that do not require physical work upon graduation.

One nurse stated:

I love surgery…but I don't think I would ever work in the OR [operating room] because of [the disability]. Unless it's just circulating, I would circulate without a problem. I don't like to scrub because…I don't wanna knock anything off…. I've thought about…being a nurse consultant….

Another nurse commented that as a result of her experiences as a nurse with a disability: “I no longer want to go back to nursing because [of] the way I've been treated. I want to look for something else.”

Both physicians and nurses were expected to compensate and often did compensate for what they could not do easily. This is consistent with previous research on nurses with disabilities. One physician noted: “If there are days that I don't feel well or I don't really feel quite up to it, I just put a positive face on it and push through.” Another said: “I basically had to give up my research career, which had been my life goal, so it had a tremendous impact on me…and how my colleagues felt about me.”

Disclosure

Both nurses and physicians expressed that they often had to try to hide their disabilities to get hired or remain in their positions. Strangely, neither nurses nor physicians seemed to have any particular compassion for each other when in the workplace, and one or the other had a disability. This was also true within the professions. If a disability was not visible, the nurse or physician was less likely to have difficulties working with colleagues in either profession. Patients were often more compassionate of the professionals’ disabilities than were colleagues. One nurse stated:

I explicitly tell the person [with whom] I am interviewing “I can do my job. It may take me a couple of minutes longer, but I can do my job.” [They] don't care. I was very explicit…that I had knee problems and why I limped and why I use a cane and why I used a walker, figuring it's better to be honest right up front so that they knew what they were getting into if they hired me. And they would say: ‘Oh, that's no problem,’ and then I would never hear from them again.

One nurse said “I guess I should be more open with my patients…before I even start doing anything but I don't wanna even tell them about it if I don't need to.” Another nurse put it this way: “I think [patients are] so grateful just to have nursing care, period. And I treat them with respect, they treat me with respect. I try…not to bring attention to myself…people don't see me in that role, I don't think [of myself] as being handicapped….”

The physicians and nurses expressed a need for increased awareness on the part of patients and healthcare professionals regarding disability. However, the nurses appeared to be more willing to verbalize directly to colleagues, and the physicians appeared to want others to lead educational efforts.

According to one physician:

And I remember years ago…talking to a [physician] from another place whom I respected very much and she said to me: “Be careful about leaving [school/hospital] because you're a known quantity at [school/hospital] and if something changes in your physical capabilities they're probably gonna stand by you. But if you go somewhere else, they're not going to feel the same loyalty.”

The belief that one should hide their disability is validated by earlier studies of nurses with disabilities (Neal-Boylan & Guillett, 2008a,b,c). Nurses who hid their disability were more likely to be hired and to be able to retain their positions, because they felt supported by colleagues and administrators. In one previous study, nurse recruiters who were interviewed could not recall ever interviewing nurses with disabilities, although they realized that they had (Neal-Boylan & Guillett, 2008a). This seem to be consistent with what nurses with disabilities had said about the measures they took to hide their disabilities.

Safety

Overwhelmingly, physicians and nurses are very concerned about jeopardizing patient safety because of the disability. Both groups often tried to compensate for what they could not do and were reluctant to ask for accommodations. Working while sick so as not to be seen as shirking one's duties, was common. This is consistent with the literature on people with disabilities (Johnson, Croghan & Crawford, 2003). Consequently, physicians and nurses often pushed themselves beyond their limits to see that their patients received quality care, often to the point when they needed to leave the job.

One nurse said:

I can't do…nursing in the traditional sense because I think it's a liability for me and I don't want to jeopardize my patients…. I can't be depended upon. I'd be the first to admit that…so how could I, in good conscience, go and apply for a job and make people [think] “oh, so you know we have a nurse now and we're gonna count on her” and then all of a sudden for some reason they can't count on me…. That also is very humiliating, to not be dependable.

This statement is exemplary of similar comments by nurses in this and previous studies (Neal-Boylan & Guillett, 2008a,b,c; Neal-Boylan et al., 2011) and explains why nurses with disabilities seem to be leaving the profession. To assume that people with disabilities will jeopardize patient safety is unfair and prejudicial (Carroll, 2004). It is possible that accommodations cannot be made for every nurse with a disability, but if the effort was made to accommodate them, then perhaps they would not need to leave because they fear jeopardizing patient safety.

Institutional Climate and Culture

The findings from this study also verified earlier findings that the attitudes and interactions of and with colleagues and administrators have a significant impact on the tone set at work for healthcare professionals with disabilities (Neal-Boylan & Guillett, 2008a,b,c, Neal-Boylan et al., 2011). Those physicians and nurses who felt supported and welcomed by those around them were more likely to stay in their positions. One nurse found an administrator who was willing to allow the nurse to work per diem and was very supportive of the nurse's need to physically compensate by moving in certain ways, because of rods in her body. However, another, despite knowing she could ask for help found it embarrassing:

On the days that it's really bad I'll ask another nurse to do it for me…cause all of my friends…they know that I have [the disability] and they know [that] some days [are] worse than others and when it's really bad I won't even try something…cause it's embarrassing. It's more embarrassing for me than anything else….

Another nurse said: “I can't work for these horrible people…. After so many years of dedicated service and I put in a lot of overtime that you don't get paid for…. But that's one thing about this disability and employment, it becomes a very humiliating experience.”

One hearing impaired physician described sitting in lectures that did not have interpreters for the hearing impaired: “I've stopped asking questions because I'm not sure the question hasn't already been answered … by another audience member ….So it's inhibiting my intellectual curiosity….”

Emotions

Collegiality and administrative support were appreciated by participants, but noted to be far more rare than was negativity. Consequently, nurses and physicians, while trying to compensate for what they could not easily do, frequently felt a diminishment of self-confidence and self-worth. Frustration at the lack of understanding that they could still think critically and perform safely often led to anger, resentment, and grief. Participants often grieved over job losses---whether or not the job change was self-motivated---over the loss of the collegial atmosphere, and respect to which they had been accustomed, over the ability to progress in their careers because they were marginalized, and over the loss of intellectual challenges that their jobs had previously provided to them. Some had to opt for no job or jobs with lowered remuneration. Others retired. However, a select few actually explained that had they not felt the need to leave their jobs (motivated either by themselves or by others) they might not have “stumbled upon” other opportunities for which they now felt grateful. Some nurses in this study as in previous studies, went back to school or looked for jobs that required less physically demanding work (Neal-Boylan & Guillett, 2008a,b,c). One physician went back for a residency in an entirely different area of medicine because he had been forced out of his previous position. He found the new career choice very rewarding and satisfying.

One nurse commented: “You start questioning yourself and thinking ‘Do they like that? Don't they like that, you know, am I right? Am I wrong? Who's doing this? Who's doing that?’ It really…gets to be so much stress…. I worry about what other people are thinking.” Another nurse said: “In many ways…I had to make some minor accommodations, and just getting used to rejection, and not taking it personally, just taking it from the source.”

Still another nurse begged for others:

To see me as a whole person and not as a person with a disability and that I can perform my duties, as needed, see that I do have skills other than nursing and that I contribute to the good of management or wherever I am working. And also that I do care for all [of] the patients I care for and families that come into our interactions.

One physician described being strongly encouraged by administration to change his specialty and seeing that in a positive way: “I think I grew a lot more intellectually by going back and doing the fellowship…. I'm really glad that I did it and I'm really glad that I decided to change paths.”

Discussion

This study served to expand and confirm findings regarding RNs with disabilities, to describe the experiences of physicians with disabilities, and to demonstrate that despite differences in education and professional culture, nurses and physicians with disabilities have similar worklife experiences.

Both physicians and nurses felt compelled to leave their jobs, switch jobs, or in some way alter their conceptions of their ideal jobs because of their disabilities. This need to alter their job and career choices made several feel stronger in their resolve to demonstrate their competence despite the challenges of having a disability. Others became angry, frustrated, and resentful. Regarding barriers presented by having a physical disability, both groups expressed wonder that colleagues in the health professions were not more supportive of them despite a professional understanding of how the disability might or might not limit them. If anything, colleagues and administrators were more likely to overestimate the impact of the disability than to understand that compensatory techniques could be used to practice safely. One physician described developing his own techniques to accommodate for his weakness in an upper extremity. The techniques were safe, but his colleagues, both nurses and physicians alike, decried his efforts because that was not the way things were expected to be done.

However, as in the previous studies of nurses with disabilities, support from colleagues and administrators were facilitators to working with a disability. In addition, in this study, patient empathy was also a facilitator.

Despite working in the health professions, the study's participants seemed to lack knowledge, awareness, or the wherewithal to pursue legally recognized workplace accommodations. The need to fit in and not to be singled out as different seemed to override the desire to pursue recognition of the need for accommodation or legal action. Different disabilities require different types of accommodations (Strobel, Fossa, Arthanat & Brace, 2006), and there is no one-size-fits-all approach.

Previous studies also found that nurses with disabilities worry that they will jeopardize patient safety. There are no documented cases of this happening, but nurses in all of the studies have expressed recognition that they should not necessarily work in all areas of nursing, but that there is still a place for them and means by which they can make contributions to the profession. The physicians in this study also worried about jeopardizing patient safety and worked hard to compensate for their limitations or changed jobs.

Limitations

Self-report is always considered a limitation in a qualitative study. The researchers did not seek to confirm the experiences that the participants described. However, exploratory, descriptive qualitative studies seek to understand the lived experiences of the patients, and the research literature regarding these two populations of healthcare professionals with disabilities is scarce. The sample was purposive and self-identified. People with less profound disabilities might describe their experiences differently. However, it is important to note that the previous studies of nurses with disabilities, which have so far involved nurses with a wide range of physical and sensory disabilities, have had very similar findings.

As in any qualitative study, the variability of the sample, the consensus of themes among participants, and the rigor of data collection and analysis are the strengths of the study. This study also benefited from a diverse research team (profession, academic setting, ethnicity, age) that included a nurse and a physician with a disability. The rigor of the study was also enhanced by the protection of human subjects, the verbatim transcription of the data, the multiple coders and repetitive coding methods, and participant verification (Cohen & Knafl, 1993).

Key Practice Points

  • Disability narrows and alters career choices and career trajectories for nurses and physicians with disabilities.
  • It is a struggle to decide whether or not to disclose or discuss the disability in the workplace.
  • It is rare for physicians or nurses to request workplace accommodations. It is more likely for them to view patient safety as their own responsibility.
  • The organizational climate and culture regarding disability are reflected in the interactions nurses and physicians have with others in the workplace.
  • Physicians and nurses experience a broad range of emotion regarding their disability-related challenges in the workplace.

Implications

Healthcare professionals, including staff and administrators, need to make an effort to retain employees (Association of American Medical Colleges, 2009) as turnover and predicted shortages are likely to jeopardize the current healthcare system (Misra-Hebert, Kay & Stoller, 2004; Waldman, Kelly, Arora, & Smith, 2004). Modifications can be made within both professions to support people with disabilities and to enable them to contribute to their professions using their abilities to think critically, problem solve, and care for patients safely. It would appear that both professions could benefit from increased knowledge regarding disability. Despite being health professionals, physicians and nurses may need to be reminded that a person with a disability brings many characteristics to the work they do, and the disability is merely one characteristic that may or may not impact the person's ability to provide safe and expert care. Educators and supervisors who foster a climate of acceptance and appreciation of what each person can do would seem to have more leverage in advising healthcare professions regarding career choices and trajectories than would those who dismiss capable professionals out of hand. It is also important to consider how much right an educator or supervisor from either profession has to tell physicians and nurses in what area of medicine or health they should practice. More detailed guidelines might be developed regarding the abilities that are actually required to perform each job, so that healthcare professionals can make informed choices for themselves about which area of their profession to pursue.

The authors of the previous studies on nurses with disabilities have already suggested that improvements and accommodations can be made that can assist healthcare professionals with disabilities in the workplace. The Americans with Disabilities Act (http://www.ada.gov/) mandates many accommodations. The literature provides recommendations for raising disability awareness and for making creative adaptations to increase safe functionality (Ferguson et al., 2009; Steinberg et al., 2002). Rehabilitation nurses, as experts on disabilities and chronic conditions can help healthcare colleagues to “come out of the closet” and to feel supported in the workplace. Rehabilitation nurses are in the position of being able to point out to healthcare colleagues that every disability or chronic condition does not pose a threat to safety or capability and they can help colleagues and administrators sort out what someone with a disability should be able to do with the proper accommodations. Preserving the confidentiality of the professional with a disability is important, but it is possible, based on these studies, that colleagues with disabilities are hoping to be recognized as people who happen to have disabilities, but who can still think and perform professionally. A rehabilitation nurse can advocate for these professionals as they do for patients. The authors of this study challenge rehabilitation nurses (and physicians) to lead formal and informal awareness raising forums and to teach their colleagues what it really means to have a disability in the workplace.

Acknowledgments

Leslie Neal-Boylan acknowledges the work and assistance of Rachel Skeete, MD, Amy Hopkins, MD, and Sarah Hartmann, BSN RN. Dr. Neal-Boylan also acknowledges a grant from the Delta Mu chapter of Sigma Theta Tau that helped fund this study.

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Biography

  • Leslie Neal-Boylan, PhD CRRN APRN-BC FNP, is a Professor in the Department of Nursing at the Southern Connecticut State University, 501 Crescent St, New Haven, CT. Address correspondence to leslie.neal-boylan@yale.edu.

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