Untapped potential: Embracing neurodiversity in medicine
Family physician Jennifer Vassel used to think she was weird. Situations affected her differently than her colleagues. She could remember exact pages from her Grade 6 textbooks. And she had always been highly sensitive to other people’s feelings—”like being a sponge,” Vassel says.
Then, she learned about neurodiversity. The term is often used interchangeably with neurodivergence to refer to the idea that there is a wide range of normal variation in the brain and no one “right” way to experience and interact with the world.
The neurodiversity movement views neurodevelopmental conditions like autism, ADHD, and dyslexia as differences, not deficits. While these differences may pose a spectrum of challenges to functioning in a largely “neurotypical” society, they’re not innately disabling and can be important strengths.
Autism care professional Aiyana Bailin explains in Scientific American that valuing neurological differences doesn’t mean denying the reality of disabilities, “but we also don’t assume that neurological and behavioral differences are always problems.”
For example, Vassel says, hypersensitivity can make working in a hospital overwhelming, especially for trainees encountering death for the first time. But the same trait helps her connect and build trust with patients quickly.
“What I used to think was weird, I now think of as what makes me different, unique, and in some ways, what I’m good at,” Vassel says. She only started feeling comfortable describing herself as neurodivergent a few months ago.
Undiagnosed and undercover
Although the neurodiversity movement has gained mainstream traction and made inroads in medical circles in recent years, 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 behaviors in childhood.
Shane Neilson, an assistant clinical professor of family medicine at McMaster University, argues in Canadian Family Physician 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, “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 autistic doctors 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 1,000 members, including Canadians 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 to the profession and reject people 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 to succeed in neurotypical settings. This may include mirroring what other people do to appear “normal,” or suppressing self-soothing behaviors 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 can 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 behaviors.
According to Shirley Moore and colleagues from the Doctors’ Support Network, a U.K. peer-support group, the full toll of masking may only become apparent 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 colleagues 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 favoring the neurotypical clinician.”
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 autistic physicians 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 postgraduate trainee in psychiatry 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 U.K. 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.”
Editor’s note: Some names have been changed to protect identities.