Shortly after he opened his first office, Michael Bobo took a life-sized plastic skull, drilled holes in it, and placed metal plates and screws in its jaws. Bobo, a maxillofacial surgeon who also has a degree in dentistry, wasn't practicing his art with this toy.

"Patients are often unclear about what we mean when we say that they will have plates on their jaws," explains Bobo, who has offices in small neighboring cities in Kentucky and Tennessee. "After practicing for a few months out of residency and seeing a fearful look come over patients when explaining these procedures, I decided a true, 3-D model such as this would be helpful. I use the skull to demonstrate the size and low-profile nature of titanium bone plates that I use to repair facial fractures."

And although it may not appear so at first, the large skulls - Bobo now has two, one for each office - also help him comply with the Americans with Disabilities Act (ADA). How? They help hearing-impaired patients understand the procedures they will undergo, and those who are visually impaired can place their hands on the skulls to feel the plates and screws. "There is generally not good, mainstream patient knowledge of the basic techniques of maxillofacial surgery, but a little extra time spent with the patient and models such as this help," Bobo says.

The ADA, passed in 1990, prohibits employers who have more than 15 workers, including medical groups, from discriminating against disabled workers. But physicians have added responsibilities under the law. Because medical offices have been deemed "public accommodations," your facility must be equipped to serve people with physical and mental disabilities. And you may need to accommodate the disabled in the way you deliver service.

According to the ADA, the term disability means a physical or mental impairment that "substantially limits" one or more of the "major life activities" of an individual. A person is also considered disabled if they have a "record of such an impairment," or is "regarded as having such an impairment."

Major life activities include bathing, walking, working, and taking care of oneself. Examples of disabilities include AIDS, alcoholism, depression, heart disease, complications from pregnancy, and hearing and speech impairments.

Generally, building owners must pay for and install items that make offices handicapped-accessible, such as special door handles and grab bars in bathrooms. If you lease your office, the lines of responsibility can be blurry. Unless your lease specifies that the landlord will equip the office, the responsibility will fall to your practice.

Moreover, you must also ensure there is no discrimination in your delivery of "goods and services" to disabled individuals. This means you must enhance your communication with disabled patients so they can understand their medical problems and your treatment plan for them.

You will have an easier time of compliance if you view the ADA like Bobo does - not as an onerous regulation, but as a way of enhancing care and the use of the office for both patients and employees.

Bobo's two offices also have ramps, wide doorways, and handicapped-accessible bathrooms. Like the skulls, these accommodations make office visits efficient for more than just disabled patients. "Many of our patients are sedated for surgery, and we will use a wheelchair to get them to their vehicles after surgery," Bobo says.

Renovations trigger law

Medical offices that were established before the effective date of the ADA do not have to retrofit their facilities to comply, but if you are renovating your building, then you must follow the rules.

A seven-surgeon orthopedic practice in Rockville, Md. used its renovation as an opportunity to outfit its office to be more amenable to handicapped patients and to improve patient flow.

For nearly 25 years, Shady Grove Orthopaedic Associates, PA, ran the way many busy practices do - its doctors tripped over each other in the hallways, shouted when they wanted an X-ray taken, and stood in the halls mumbling into their Dictaphones.

Patients rolled in and out in their wheelchairs through tight hallways, or struggled on crutches to reach an exam room. Some couldn't use the office bathroom and had to use the public facilities out in the building hallway.