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