The Influence of Photographic Representations on U.S. Medical Students' Attitudes and Beliefs About Persons With Disabilities: A Qualitative Study.

Phenomenon: There is a crucial need to more deeply understand the impact and etiology of bias toward persons with developmental disabilities (PWDD). A largely unstudied area of concern and possible intervention is the portrayal of PWDD in medical education. Often, medical photographs portray PWDD with obscured faces, emotionless, and posed in an undignified way. This exploratory, qualitative study aimed to explore how photo representations of PWDD influences medical students' attitudes and beliefs toward disability. Approach: We recruited 10 medical students from a single medical school in the northeastern United States to participate in in-depth, individual semi-structured interviews via Zoom. During the interviews, we asked students to reflect on and respond to two image sets of PWDD: a standard image set, which were photos from medical textbooks, and a positive image set, which were photos from the U.S.-based disability nonprofit, Positive Exposure. Using thematic analysis underpinned by the Health Stigma and Discrimination Framework, we coded and organized the transcripts into four themes that characterized participants' attitudes and beliefs about PWDD. Findings: The four themes we identified were as follows. Humanization vs. dehumanization: Standard imagery characteristics (e.g., black bars, unnatural posing, lack of clothing) were perceived as dehumanizing and raised concerns about consent and autonomy, whereas positive imagery characteristics (e.g., clothing, natural poses, nonclinical settings) were seen as humanizing and enhanced perceptions of agency. Quality of life: Standard imagery often led to assumptions of compromised quality of life, while positive imagery suggested a good quality of life. Discomfort vs. comfort with communication in a clinical setting: Dehumanizing portrayals increased perceived difficulty in establishing rapport, while humanizing imagery mitigated these perceived barriers. Diversity: Image sets showcasing a diverse spectrum of presentations for a given diagnosis were valued for medical education. Insights: We conclude that photographic representation of disability in medical education can influence medical students' attitudes and beliefs about PWDD. Photographic elements can either humanize or dehumanize, with humanizing representation leading to more positive attitudes and therefore also an educational benefit. Thoughtful and inclusive visual content is needed in medical education to encourage positive attitudes and foster a more empathetic healthcare environment. Our results support future plans to further investigate how photo representation affects attitudes in a larger sample. Additionally, our study's insights contribute to the ongoing initiative Textbook Beauty, providing guidance for the selection of photography to improve attitudes toward disabilities.