Neurodiversity in practice: autistic anaesthetists can be an asset | Association of Anaesthetists

Neurodiversity in practice: autistic anaesthetists can be an asset

Neurodiversity in practice: autistic anaesthetists can be an asset

This article was first published in the December 2020 issue of Anaesthesia News. 


The author on the left, with Judy Singer, who coined the term “Neurodiversity” in 1998.

Early in my anaesthesia training I attended a seminar at the Association of Anaesthetists, where a study comparing the psychological traits of anaesthetists and physicians was discussed [1]. The debate centred on whether anaesthesia attracted already eccentric doctors or whether anaesthesia made us odd, and regardless of causality, the consensus was that we’re a fairly unusual bunch. I knew at that point that I’d made the right career choice, even though I didn’t discover until years later when my son was diagnosed, that I’m not just odd - I’m actually autistic.

Autism is a complex, lifelong neurodevelopmental condition that affects the way in which an individual experiences the world and communicates with others. It is heterogeneous in presentation, with those diagnosed ranging from profoundly disabled individuals requiring full time care to highly intelligent high-achieving individuals, who nonetheless experience significant differences in the way they perceive the world compared with those who do not share the condition. It can be considered an invisible disability, and it comes under the umbrella term ‘neurodiversity’ that also includes attention deficit hyperactivity disorder (ADHD), attention deficit disorder (ADD), dyslexia and dyspraxia.

Increased recognition of autistic spectrum conditions in recent years means that more students are entering medical school with an existing diagnosis.

Increasing recognition of disability and diversity in society has led to bodies such as NHS Employers and the GMC developing equality, diversity and inclusion strategies. The GMC states ‘as the professional regulator, we firmly believe disabled people should be welcomed to the profession and valued for their contribution to patient care’ and it recognises that ‘a diverse population is better served by a diverse workforce that has had similar experiences and understands their needs’ [2].

Autistic spectrum conditions (including that previously termed Asperger syndrome before publication of the latest classification manual for psychiatrists, the DSM-5) occur in around 1% of the population. There are no published prevalence rates for doctors, although 1% of respondents to a survey exploring GPs’ confidence in treating autistic patients indicated that they were on the autistic spectrum themselves [3]. There are no corresponding figures for other specialties, although anaesthetists certainly appear to be over-represented in an online network of neurodivergent doctors, and indeed anaesthesia may select for ‘Aspie’ traits. Autism was traditionally considered a predominantly male condition, but more recently it has been recognised that it presents differently in women, and the rates of female autism are far higher than previously thought. Increased recognition of autistic spectrum conditions in recent years means that more students are entering medical school with an existing diagnosis. For others, it is only when the demands of postgraduate training or independent practice, perhaps coupled with adverse life events, overwhelm existing coping strategies that the diagnosis first becomes apparent.

Autism is associated with co-occurring psychiatric disorders in up to 80% [4], notably anxiety and depression. Suicide rates in the autistic population are significantly increased [5], and as we know that suicide is a particular concern for anaesthetists we can surmise an even greater risk for autistic anaesthetists, particularly those who remain unsupported and possibly undiagnosed.

Anaesthesia can be a good lifestyle choice for an autistic doctor. 

While many are practising successfully, the recurrent narrative among late-diagnosed autistic doctors known to me is one of personal distress, career difficulties and often a truncated career. Change of career or early retirement are common, yet with specific support many of these difficulties are remediable and timely support could lead to increased retention of highly skilled colleagues. Following my son’s diagnosis and through my work with AsIAm, Ireland’s national autism charity, I recognised that I also view the world through an autistic lens, and hence the solutions to commonly occurring difficulties encountered by autistic doctors are relatively easy for me to see.

High-achieving autistic individuals are intensely focused perfectionists with high attention to detail, and often have particular strengths in pattern recognition, all skills which are clearly advantageous in anaesthesia. Autistic people are often creative thinkers and problem solvers, and contrary to popular assumptions have been shown to exhibit high degrees of empathy.

Anaesthesia can be a good lifestyle choice for an autistic doctor. Generally we deal with patients one at a time, in a sequential order. It is procedure-based and solution-focussed, which is attractive to innovative but concrete thinkers. Adherence to routines and repetitive behaviours are key traits of autism, and these tend to feature heavily in anaesthetic practice.

Social challenges

Social challenges and sensory differences are the main issues for more able autistic people, particularly before diagnosis. Innate difficulties with communication can be overcome easily by highly intelligent doctors given appropriate training, ideally with the benefit of autism-specific tutoring delivered by autistic professionals. Communication with patients is relatively structured and task focused, which is ideal for autistic doctors, and the skills required can be easily learnt, indeed are specifically taught in modern medical training.

In contrast, interactions with colleagues are more socially based. This is where an autistic trainee or consultant colleague may struggle most, and he or she will often be found on the periphery of the team or may even be excluded entirely from the social group. Over-literal interpretation of instructions, miscommunications, misunderstandings, and unintentional use of non-verbal communication or misinterpretation of body language can all cause difficulties. This may lead to interpersonal conflicts, resulting in social isolation, social anxiety and depression. An autistic colleague may appear anxious, emotional, and easily upset, or in contrast may be reserved, aloof or distant.

Alternatively, highly intelligent autistic people, particularly women, often learn appropriate social skills and can appear to interact well, often becoming a popular and valued member of a department. However, it must be noted that such interaction is cognitive not intuitive, and the intense effort required to maintain it is not sustainable indefinitely. The health effects of such ‘masking’ have recently been highlighted [6], and it is vital therefore to find a balance between social interaction and restorative solitude.

Challenges with executive functioning are a feature of autism, and may present as a disorganised ‘scattered’ doctor who struggles with paperwork, deadlines and time keeping. Specific support strategies targeting executive functioning are particularly helpful in such cases, and the best professional to advise on an individual basis may be an occupational therapist familiar with autistic spectrum conditions. Increasing awareness in society generally leads to increased availability of resources to support autistic colleagues, and funding for assistance may be available under the ‘Access to Work’ scheme in the UK. Equality legislation requires that reasonable adjustments are made, and input from an autism-aware consultant occupational physician is invaluable in this regard.

The typical operating theatre environment can be a sensory nightmare for an autistic trainee, who may take longer to acclimatise than peers.

A monotropic thinking style, in which a small number of interests pull the autistic person more strongly and use up a good deal of the person’s processing resources, can lead to sustained passionate interest in a particular topic, culminating in a high degree of expertise. However, this can also lead to difficulty switching focus and possibly idiosyncratic practice in a socially isolated doctor. This high degree of focus can be particularly beneficial in research, but executive functioning challenges may mean that an autistic trainee may be unable to juggle research interests alongside a busy clinical role. A period of dedicated research might be sensible if this is their specific interest, or a training requirement.

Sensory issues can be particularly disabling for autistic people, and the degree of discomfort should not be underestimated. Noise is a common sensory trigger as is bright light, particularly fluorescent light. The typical operating theatre environment can be a sensory nightmare for an autistic trainee, who may take longer to acclimatise than peers. Multiple beeps, alarms, music, smells, tangled lines and tubes, and challenging communication from behind surgical masks all add up to a significant extra cognitive load, which should be taken into account when evaluating an autistic trainee. Coupled with the difficulty of making transitions, negotiating new social relationships means that the early days of a new rotation will be particularly stressful for an autistic trainee, and unfortunately this can have negative consequences as first impressions are formed just at the point of greatest stress. Fostering a culture of tolerance and acceptance of diversity will offset this, and allow a trainee to perform optimally more quickly.

The value of a supportive and understanding mentor cannot be overestimated. 

It should be appreciated that autistic people who have made it through medical school have generally put enormous effort into learning communication and social skills, and any attempt to reciprocate on the part of colleagues is hugely beneficial and always appreciated. Specific advice for communication with an autistic colleague would include being explicit with directions, and avoiding hints or mixed messages. The degree of clarity required to transmit a message accurately may seem blunt or even rude, but this is usually gratefully received. If interpersonal conflicts continuously occur between a consultant and trainee, the best approach may be to follow the procedure in aviation and ‘do not pair’ a trainee and consultant who have difficulty working with each other. Such situations are usually due to a communication style which is particularly difficult for an autistic person to interpret. It is important to recognise that a frazzled brain cannot learn, and if too much effort is going into decoding a colleague’s non-verbal communications, little else can be processed. Polarised impressions of a trainee may be a clue to an underlying neurodevelopmental condition. Where possible, there may be a disproportionate benefit in pairing a trainee with the same trainer for an extended period, rather than the usual arrangement in which the trainee works with a different consultant each day.

A significant amount of learning takes place in the social milieu of a trainee cohort. This cannot be assumed to be happening for an autistic trainee who may not be part of the group, so it will be important to check for gaps in knowledge. The value of a supportive and understanding mentor cannot be overestimated. Feedback must be clear and unambiguous. Do not use figurative language or hints. In the event of an unexpected response or behaviour, it may be that the autistic trainee has interpreted rules or instructions literally, so check understanding of the intended message. Explicitly state changes to plans that others may pick up instinctively; for example, if an event is rescheduled from its usual location an autistic trainee might not notice colleagues going in a different direction, and may not be included in online groups where key information is shared.

Beware simulation-based teaching techniques and OSCE exams. Allow for additional processing challenges from incongruent input that non autistic participants would filter out unconsciously. Avoid asking questions in a group training session without explicitly clarifying the required response. Expect changes and transitions to be challenging, and allow time to process. An autistic trainee might have an inconsistent, ‘spiky’ profile, displaying excellence in some domains while underperforming in others. This might all add up to a prolonged or stepwise progression through training, which should be acknowledged and positively encouraged.

Challenges are situational and often transient. Sensory overload is real. Beware of assuming that a trainee is struggling with the job itself, when in fact the problem is simply a stressful sensory nightmare of the operating theatre and a colleague who communicates in a non-autistic-friendly style. Understanding, acceptance of difference, and minimal adjustments to the environment can have disproportionate effects in such circumstances. 

Be aware of the additional effort it takes to socialise and appear part of the team, and be understanding when someone needs solitude. It can be confusing when a colleague happily chats one day, but sits in silence appearing to ignore people other days. Be understanding, be tolerant.

A high degree of social masking often means that the condition remains hidden. It may be that a doctor’s professional life is unremarkable but their personal life is chaotic. Life events and unexpected changes may mean that demands exceed an individual’s capacity to cope, which can result in sudden and catastrophic decompensation. This may require a period away from work, but with awareness of the specific challenges arising from autism, many of those doctors can be supported to return to practice. It is my opinion that an autistic spectrum condition should be specifically considered whenever a doctor presents in difficulty, particularly when the difficulties arise after any sudden change to professional or personal life.

It is important that we come to see autism as part of the range of human diversity, in order to appreciate the benefits of our existing diverse workforce, improve retention, and smooth the path for neurodivergent anaesthetists of the future.

Recognition of autism in oneself or colleagues has significant benefits, particularly in reducing the need for continual masking, leading to better communication and increased team cohesion. The benefits of having a diverse workforce are increasingly recognised in the corporate world. Major companies such as Microsoft now focus on diversity and inclusion [7], and demonstrate that teams with a variety of thinking styles and backgrounds are more effective. A recent publication in Lancet Psychiatry entitled, 'Autistic doctors: overlooked assets to medicine', identifies that increasing numbers of doctors are being diagnosed, and calls for greater understanding and support for autistic doctors to aid retention of highly trained clinicians who may not ‘conform to existing systems favouring the neurotypical clinician’ [8].

Autism awareness

Autism awareness and understanding are most reliably provided by those who are themselves autistic, and members of Autistic Doctors International, a peer support group founded by me in 2019, are leading the way. The ‘International Conference on Physician Health 2021’ to be held in London next April will feature a poster presentation on the development and composition of the group, and a workshop on ‘Supporting autistic doctors’ [9].

As anaesthetists, we are a highly focused group of individuals within the wider medical community, with an inspiring capacity to come together for the greater good, as shown by the response to the ongoing COVID-19 crisis. It is important that we come to see autism as part of the range of human diversity, in order to appreciate the benefits of our existing diverse workforce, improve retention, and smooth the path for neurodivergent anaesthetists of the future.

If you are considering that autism may be relevant to you personally, I would urge you to seek an opinion from a professional experienced in diagnosing autism, as the benefit of diagnosis is enormous. There are online resources available such as the AQ10, which is recommended by the NICE guidelines as a screening tool [10], or the more comprehensive AQ 50 [11]. The Ritvo Autism Asperger Diagnostic Scale – Revised [11] is particularly useful for those who have learned to mask effectively, but none of these can replace a formal diagnostic process. The NHS Practitioner Health Programme is an autism-aware service that is highly recommended for those in difficulty. There is also a supportive online network of autistic doctors [13]; having a formal diagnosis is not a requirement to join the private group. Send a message via the public Facebook page, or feel free to contact me directly.

Acknowledgements: I am deeply grateful to Dr Nancy Redfern, Association of Anaesthetists Mentoring Lead, for her assistance in negotiating the obstacle course that was returning to clinical practice after six years absence, and for her encouragement and assistance in the writing of this article.

Mary Doherty
Consultant Anaesthetist

Twitter: @AutisticDoctor

Note on terminology: “Autistic person” is used in preference to “person with autism” since this is the overwhelming preference of autistic adults in multiple surveys, and my own personal preference.


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