Special Educational Needs and the Study at the Field of Medicine

The study and the profession at the field of medicine involve high demands on mental and physical capabilities. The objective of this study is the following issue: in what ways mainly healthy students evaluate opportunities of students with special educational needs (SEN) to study medicine. It is based primarily on their experience of the studies and on their medical practice. To meet the above objective, a questionnaire survey method has been used. The results of the survey could be concluded with general recommendations: the study of general medicine is fully manageable for students with certain SEN such as slight visual or hearing impairments, specific learning disabilities, and internal diseases, while it is manageable in a limited way for students with physical disability of legs. The study of students with SEN such as severe visual or hearing impairment, locomotor disability of the upper limbs and disability of fine motoric skills and mental illness, will be very difficult and complicated even if the university considerably adapts to these conditions. In the case of students with SEN, making the decision regarding future profession in health care should always be realistic and based on individuals and with respect to their future employability.


Introduction
The study of general medicine has always been one of the most prestigious and most demanding university studies. The amount of information and skills that must be mastered by the future doctor during the course of the study is constantly increasing. The best secondary school graduates have always been enrolled to the study area of General Medicine, however, a high percentage of them do not complete their study (Rosebraugh, 2000). One can just guess, which students do not complete the study because the mismanagement of the actual curriculum and how many of unsuccessful students would have been successful if a required support for students with special educational needs (SEN), due to health impairment or disability, had been provided to them (Kleňhová & Vojtěch, 2011;Faigel, 1998). In this sense, these special educational needs are further understood in the text.
The process of widening access to students with special educational needs cannot be understood as their prioritizing but as the creation of supportive measures during the study, which will enable them to complete the study in full extent (Zezulková & Krhutová, 2009) and strengthen their personal autonomy (Krhutová, 2013) and help them to reduce social barriers (Cook, Griffin, Hayden, Hinson, & Raven, 2012). There are, however, fields of study, where even the maximum degree of adjustment of learning environment does not allow the student to complete all obligations in full extent and thus comply the requirements for the profession performance.
Non-medical healthcare fields and medical professions occupy a special position among other fields of study; there are known as professional fields and their content is strictly defined by legal standards. In the process of equalization of opportunities for college students with special educational needs, the university (institution) has only limited possibility to modify education as strict accreditation requirements and applicable health legislation must be fully met.
The study focuses on the issue in what ways mainly healthy students evaluate opportunities of students with special educational needs to study medicine. It is mainly based on their experience of the studies they have already completed or their medical practice.

Research Method
The main objective of our survey was to determine how the students of general medicine, evaluate opportunities of students with special educational needs to study general medicine, based on their experience. In order to meet the stated goal, the survey method was chosen, the respondents of the target group were offered the opportunity to answer questions about the given issue. Participation in the survey was voluntary, the students participated in the survey based on their decision (Chráska, 2007).

Target Group
The target groups of the questionnaire survey were students of all years of general medicine at the Ostrava University in Ostrava.

Data Collection
The questionnaire survey was used for data collection. The questionnaire sur-  (Sochorová & Závacká, 2014) and again in the academic year 2015/1016. During the first questionnaire survey, 370 students of general medicine were addressed through the university e-mails while 418 students were addressed two years later. In the introductory text, students learned the target of the survey and that the participation is voluntary.
The data were collected electronically through an online form, in which respondents selected from the available answers, but they also had an opportunity to add free-text comments.

Categories of the Specific Education Needs
For the purpose of assessing the student's functional abilities in relation to study duties, students with specific needs are divided into categories according to the potential need to modify the study conditions. When creating categories, the methodology of the Ministry of Education Youth and Sports (MEYS) has been used (MEYS, 2014). The methodology distinguishes typology of disabilities for the purposes of financing the increased costs associated with the provision of studies for students with special needs.
For the purposes of the survey, this typology has been modified into the category of students with internal diseases where chronic somatic diseases and mental disorders with regard to psychological demands of the study and profession were separated.
Categorizations of specific needs in our survey are as follows: (A) Students with vision disabilities.
(A1) Slightly visually impaired students/eyesight users (Students work with common document formats; image editing involves enlarging optical character or other changes).
(A2) Severely visually impaired/touch/voice users (Student work with tactile printed documents or screen readers, requiring editable format text document or content and form adapted document).
(b) Students with hearing impairments.
(b1) Hard of hearing/user of verbal language (student receives information and communicate through verbal language, Czech language).
(B2) Deaf/sign language users (student receives information and communicates through sign language, Czech sign language).
(C) Students with physical disabilities.
(C1) Lower limb disability, paraplegia (for independent movement, students need and use other personal devices, supporting sticks, mechanical or electric wheelchair).
(C2) Students with disabilities of the upper extremities and fine motoric skills (student is not able to perform effectively such tasks as taking notes by hand or on the keyboard, manipulating tools and devices that are necessary for fulfilling all study obligations or manipulation with objects of everyday use). (E) Student with internal diseases (illness objectively disables the student to fulfil study requirements in a standard way or requires special organizational demands from the school).
The questions of the form In the introduction, the respondent was acquainted with the aim of the survey and with specific educational needs. Then it was followed by questions that ascertained all the information concerning the respondent. In the next part, the respondents were asked to express their views according to their experience and answer how the student is able to handle the study of general medicine in each category of specific needs, namely:  Theoretical part of study usually in the form of monologue or dialogue of the teacher with the student with the support of audio-visual equipment,  Practical education led at school, at school laboratories takes place in specia-

Characteristics of Respondents
A total of 83 respondents completed the survey, i.e. 10.5% of the total number of respondents, where 69 respondents participated the survey for the first time and 14 respondents repeatedly. A total of 47 women and 22 men from the total number of respondents participated in the first survey that corresponds to the ratio of surveyed students. In the second survey, the answers of 14 students who participated in the initial investigation were there collected and analyzed independently, see below.
Distribution of respondents according to the year of study is shown in Figure   2. The smallest number of respondents was from the last sixth year of study,    were answered by 24 students (in the third and fourth year of study). Six students out of the total number of respondents were students with special educational needs.

Results of the Survey
Outcomes of the survey can be presented from two perspectives by categorizing specific educational needs or by division into units according crucial methods of teaching (theory, practical instruction, clinical internship, practical placement).
In terms of career decisions for applicants with special educational needs, the first option will be used, and according to various categories of students with special educational needs, it is shown which crucial part of instruction, according to respondents' opinions, could be a major obstacle to successful completion of the study.

Visual Impairment
Student typology A1 (light visual impairment), according to the above typology, works with common document formats and adjustment of image is based on the enlargement of the images and other optical changes The results show that light visual impairment is not considered a major obstacle to manage the study of general medicine, only 2 respondents out the total of 69 students take the view that this type of special needs would be a barrier to complete the practical instruction conducted at school (work laboratory, etc.). The reason could be the fact that within the first three years of study curriculum, practical subjects that require working with a microscope and simulation of processes via PC are included.
Completely different situation arises in the case of a student with severe visual impairment, who works with tactile printed documents or screen readers and requires an editable text document format, and content and form adapted documents if necessary. These results are presented in Figure 3, the majority of students considers unrealistic to complete required lessons in the full extent even when the learning materials, teaching and evaluation methods are modified.

Hearing Impairment
The opinions of respondents concerning students with a hearing impairment B1 are similar to those of students with mild visual impairment that is illustrated in the diagram, where visually dominates light areas, a view that the student with such a kind of disability is able to manage the studies without modification or with some occasional modifications, as confirmed by a particular situation at the Faculty of Medicine.
For a student with a hearing impairment typology B2 (deaf/sign language  which could be very difficult with regard to above mentioned mandatory standards. It should be kept in mind that a doctor must be able to communicate with patients, and it could be a fundamental problem in this profession, a communication barrier between a doctor and a patient could affect the speed while determining diagnoses and appropriate treatment. Nevertheless respondents can see complications to manage the curriculum at school courses (theory and practice).

Physically Handicapped
Also respondents' views on managing the course requirements by students with  be able to handle the theoretical part of instruction even at maximum possible adaptation. In Figure 5 presenting these opinions, prevailing dark fields (such student is not able to complete some obligations in full range and some obligations would need to be eventually changed) in all four learning units can be seen.

Students with Specific Learning Disabilities
Respondents' opinions on fact how a student with a specific learning disabilities (typology D) will handle obligations arising from study plan are presented in Figure 6. From the outside view, the most difficult for such students seems to be completing the theoretical part of instruction. However, previous experience with the students of general medicine at the Faculty of Medicine of University of Ostrava indicate that in this case the handicap was significantly outweighed by a high motivation and diligence and those students were most successful ones. This fact was, in the case of students with dyslexia, also confirmed by international studies (McKendree & Snowling, 2011).

Students with Internal Diseases
For the purpose of the present observational study, the type of specific needs in category E (student with an internal disease) was split into two separate subtypes. Insight into the results presented in Figure 7 and Figure 8 shows that this division has its own justification. Figure 7 presents the views of respondents on mastering the study requirements in the case of students with special educational needs suffering chronic somatic diseases while Figure 8, presents the views on students suffering mental disorders.   In the comparison of the two images No. 7 and 8, at first sight, there is a distinct difference in the "detriment" of students with specific needs based on mental disorders. In this case, a high percentage of respondents in all learning units consider that such a student will not be able to fulfill study requirements with regard to a large degree of psychological stress, as the demands on the knowledge and skills of future physicians are very high.

The Development of Respondents' Opinions during the Study
Due to the fact that the survey was carried out in two waves, some respondents participated repeatedly. These outcomes were evaluated separately and com-  Figure 9 and Figure 10. women) that is about 3% more than the total number of respondents among students of medicine. In the study there were included students from all the study fields, types and years of the study. The poll was conceived in a similar way, the core part of the questionnaire consisted of questions in which respondents considered if the student with specific needs would be able to handle study duties. These duties were divided into four separate areas-the theoretical part of teaching and three different ways of practical teaching-in the view of the prevailing teaching methods.
Respondents considered that the least difficult would be to master theoretical instruction mainly for students with a low visual impairment and motor impairment of the lower limbs. Mastering studies with great support and modified teaching methods were attributed to students with severe visual and hearing impairments. On the other hand, 41 respondents (25%) considered psychological disorder to be a major barrier to master theoretical instruction.
When assessing teaching in school laboratories (students do not come in direct contact with the patient, mostly use models and trainers and train the rou- This handicap is a major barrier especially in mastering manual skills (health technician, physiotherapist and others). After practicing basic skills in school laboratories and models, students of non-medical professions continue to practice their studies directly in the health facility. The teacher or the mentor is still present in the classroom, and the student is under constant supervision. In this part of the course, the student is involved in regular medical care, and in most fields there is direct contact with patients. In all categories of specific needs, here significantly increased the number of respondents, who believe that a student with specific educational needs is unable to handle the training. Similar results were detected in the case of upper extremity and soft motor skills impairment, which were found to be the biggest problems according to the respondents. It was followed with severe visual and hearing impairment, lower limb disorder and mental disorders. 12 respondents (7%) believed that even a visually impaired student would not be able to complete all practical exercises. For example, in the physiotherapist's profession, the primary examination of the patient is based on a visual evaluation of the condition and any visual impairment makes this initial examination more difficult.
Further degree of practical instruction is a continuous individual practice. It usually occurs during holiday periods when the student is fully involved in the activities that take place in a health facility. Students usually seek such facility at their hometowns. Here, the student has to demonstrate almost full professional knowledge and ability to work independently, in accordance with Act No. 105/2011 Coll., On conditions for acquiring and recognizing competence to perform non-medical healthcare professions and performing activities related to providing health care, as amended, to perform a profession without professional supervision. Similarly as in previous types of practice, respondents saw the greatest complications in students with upper limb disabilities, motor impairment, and students with severe visual impairment. On the contrary, the smallest complications were seen in students with a slight visual or auditory disability, 38 respondents (23%) assumed that the student was able to complete the practice in case of light visual impairment.
The following tables summarize and compare outcomes from the field of inquiry surveys. They compare students' views on the management of study duties in the fields of non-medical field and general medicine. Students with specific needs are divided into categories A to E for the purpose of comparing both poll surveys according to the used typology, category D in the 2013 survey for non-medical fields of study was not used. Always the two highest values are highlighted in bold. Table 1 compares the individual teaching units (there are always four theoretical parts of the general and non-medical branches, the theoretical and practical lessons at school at the same) in the situation when the respondents expressed the opinion that the student would be able to handle the duties without modification or only with small modifications, such as modification of the test method. From the table it is clear that the outcomes of the surveys are similar, where the highest percentage of respondents leaning towards specific learning needs based on light visual impairment, light hearing impairment, and specific learning disorders (general medicine only).  Table 2, on the other hand, shows which specific educational needs, in the opinion of the respondents, would probably be the reason for not meeting full-time study requirements. Even here the comparison of the study of general medicine and paramedical professions is similar the highest percentage of respondents considered unrealistic to fulfill study duties in the case of specific educational needs based on severe visual impairment, fine motor impairment and psychological illness. Table 3 and Table 4 then present the results collectively for all four units on average (i.e., how many percent of respondents consider all study duties for a given category of specific needs to be manageable/unmanageable).  Table 3 and Table 4 clearly show that although the percentages differ, the highest values in both cases are the same. Divergence can be found in Table 3 for the category of B2 specific needs (sign language use) where respondents expect lower percentage of mastering study duties in non-medical professions, which is probably due to the higher need for direct communication with the patient. In Table 4, this difference was also shown for category B1 (hearing-impaired) here is the percentage of respondents with the view that study is not manageable, more than twice as high. A significantly high percentage of non-medical respondents also exclude full-time studies in the category of  specific educational needs based on lower limb disabilities. This fact can be attributed to the respondents from individual non-medical fields of study, which are very physically demanding (e.g. physiotherapist, rescue ranger).

Discussion
Graphical outcomes from the previous section present answers to the questions from the survey. This survey has several limitations, of course. Its generalization can be problematic because of the low response rate among students. It is likely that the survey was answered only by students who were interested in this issue.
And although it is seen that after graduation or during the study, respondents could change their opinion on this issue, certain conclusions can be formulated.
Despite the above limitations, this study has particular relevance mainly for educational counseling in choosing a future profession.
In the case that classification of specific needs into categories A to E is kept, the survey can be concluded with the general recommendations: study of general medicine is fully manageable for students with special educational needs based on a lightweight visual or hearing impairment, specific learning disabilities and internal diseases and, in a limited form, for students with lower limb impairment. The study for the students with special educational needs based on severe visual or hearing impairment, locomotor impairment of the upper limbs, fine motoric skills and mental illness will be very complicated even after considerable adaptation from the faculty. And there is a high probability that such student will not be able to fulfil all obligations of the curriculum, and therefore the requirements for professional qualification. Of course, it always depends on the particular level of specific educational needs, because everyone is individual and everyone with is coping with "the same degree of" handicap in the different way.
Study of general medicine or rather the choice of non-medical (paramedical) profession?
It is often the case that a secondary school student with specific educational needs considers future applications in health and medicine because he has encountered more often with the environment of health care facilities. It may then, considering its specific educational needs, consider whether to choose (or, as will be shown below), a "simple" or "less demanding" study of some medical non-medical profession.
Comparison of the two surveys revealed the overwhelming consensus. During the percentage comparison of variants of answers some derogations has been found, which could be found in the category of specific educational needs of B2 (usage of sign language), where, in paramedical professions, respondents expected lower percentage of mastering study requirements, that will probably be given by greater need for direct communication with the patient. Significantly higher percentage of paramedical respondents also exclude full mastering of the study in categories of specific educational needs based on impairment of lower limbs. This fact may be given by proportion of respondents from individual non-medical fields of study, among which very physically demanding professions (e.g. physiotherapist, paramedic) were included.
In practice, there could be problems that may arise when teaching students with special educational needs, especially in patient care during clinical exercise, or in interactions with teachers, mentors of clinical practice and communication with a patient and a family (Ikematsu et al., 2014).

Conclusion
The issue regarding specific educational needs in healthcare and medicine is a very important topic in every case and it is very disputable. The applicants with special educational needs and their decisions about future professional specialization in health care should always be assessed realistically individually and with respect to future employability in the labor market. Although it is possible to modify the study, to maximally adapt it-of course, while observing all the given legal standards of vocational education-after graduation, the graduate goes into practice. He enters an ordinary medical facility, where he works in shifts is a common practice. Now the following questions arise: Will the employer be helpful and welcoming to the specific needs of a new employee? Will the employer allow the employee to adapt to the environment, for example, by modifying working environment or way of communication?