Untapped potential: embracing neurodiversity in medicine

Undiagnosed and undercover

Although the neurodiversity movement has gained mainstream traction, medicine has been slow to acknowledge or accommodate neurodivergence within its ranks.

Exact numbers of neurodivergent doctors are unknown, and studies on neurodiversity in medicine are mostly small, qualitative, and focused on autism.

Many people may not know that they’re neurodivergent until adulthood — often when demands at home or work exceed their ability to compensate for differences. Women and high achievers, especially, may be overlooked or misdiagnosed if they don’t display disruptive behaviours in childhood.

Shane Neilson, an assistant clinical professor of family medicine at McMaster University, argues that neurodivergence may be under-identified in physicians precisely because medicine filters for “high-functioning, intelligent, and conscientious” people whose strengths may mask difficulties.

Meanwhile, Neilson notes in Canadian Family Physician, “intense internalized stigma due to professionalism norms discourages anyone from seeking help or accommodation.”

According to an editorial in the British Journal of General Practice, many neurodivergent doctors may remain undiagnosed and undercover for fear of workplace discrimination.

“We thought we were alone…”

However, a growing community of doctors with autism is challenging the notion that neurodivergence is incompatible with a medical career.

Mary Doherty, an Irish consultant anesthetist, discovered she was autistic in her mid-forties. In 2019, she founded Autistic Doctors International, a peer-support and advocacy group, because she was “craving autistic peers in medicine.” The group now has nearly 1000 members, including Canadian physicians like Vassel.

“We all thought we were alone,” says Doherty. “Just to be able to come together with a group of people who understand has been phenomenal.”

Most of the group members don’t fit the category of “doctors in difficulty,” though many have experienced challenges at work, usually related to fitting in with colleagues or organizational hierarchy, rather than patient care.

Doherty says it’s a “huge loss” for medicine to overlook neurodiversity as an asset or reject people from the field over things like social awkwardness or lack of eye contact, for example.

“I mean, medicine selects for autistic traits,” she says. “Perfectionism, attention to detail, that dogged determination to stick with an idea until it gets resolved, work ethic, loyalty, honesty.”

Embracing neurodiversity in medicine could also bring greater understanding and empathy for neurodivergent patients, writes Georgina Taylor in the Australian Journal of General Practice.

Behind the mask

Neurodivergent people often feel pressure to “mask” or compensate for differences in order to succeed in settings that favour neurotypical behaviour. This may include mirroring what other people do to appear “normal,” or suppressing self-soothing behaviours like fidgeting or hair twirling, also known as “stimming.”

Keeping up appearances can be exhausting, says Josée*, a forensic pathology resident. Josée says that specializing in pathology, where she could work at her own speed, allowed her to “survive and also thrive.”

“I get to be myself when I’m working on my own,” she explains. “It allows your brain to think about other things when you don’t have to think, ‘Did I say hi properly to this person this morning? Did I ask enough questions about them?’”

Emerging evidence has linked masking with increased anxiety, depression, and suicidal thoughts and behaviours.

According to Shirley Moore and others from the Doctors’ Support Network, a peer-support group in the UK, the full toll of masking may become apparent only when a physician reaches a breaking point, “sometimes catastrophically, in the form of a meltdown.”

Yet, dropping the mask can be risky, too. “Different learning needs are often overlooked and those who do not fit with society might find themselves undermined or scapegoated,” Moore and coauthors write in The Lancet Psychiatry.

As health care faces increasing recruitment and retention difficulties, they note, “employers, managers, and colleagues can no longer afford to overlook the potential of autistic doctors purely because these doctors do not conform to existing systems favouring the neurotypical clinician.”

Accommodating difference

Alex*, an anatomical pathology resident who was diagnosed with autism as an adult, says there’s often misplaced concern about the ability of neurodivergent doctors to connect and empathize with patients.

On the contrary, Alex has found it easy to relate to patients because “most people have a good grasp of how a doctor should act and there’s a very clear script.”

“What’s very difficult is the interpersonal interactions with the people you work with and figuring out what they expect of you,” Alex says. Constant changes in routine and having to renegotiate accommodations repeatedly during training have also been challenging.

Workplaces expect physicians with autism to “spend every second of their day pretending to be as non-autistic as possible,” Alex says. “But when you ask for one tiny thing to make things easier for you [such as asking for orientation at a new job or not to be on-call on the first day], people act like it’s a really big deal.”

More open discussion of neurodiversity in medicine is needed to facilitate peer and workplace supports, according to a paper in BJPsych Open. The authors point out that “those who have been able to achieve suitable accommodations, often without realizing why they were needed, have flourished.”

Evidence on how to support neurodiverse doctors is limited, and types of accommodations will likely vary depending on the individual.

Daniel Robinson, a psychiatry trainee who has ADHD, suggests that learning environments could be improved by increasing the diversity of senior role models, providing timely feedback, and using teaching strategies that make visible the thought processes involved in complex tasks and allow trainees to elaborate on their own thinking.

Medical training should also encourage introspection to help physicians identify if they’re neurodivergent early in their careers, says Andrea*, a family physician and preventive medicine specialist who learned she had autism and ADHD years after medical school. “Have some reflective exercises early on so that people can actually understand that might be them,” she says.

Advocacy efforts by Doherty and others in the UK have helped to kickstart conversations about neurodiversity internationally, says Elizabeth*, a Calgary-based physician who was diagnosed with autism a few years ago. But those conversations are “still very much hidden” in Canada, she says.

“There has to be a recognition that we are here, we’ve always been here, and we’re not going anywhere.”