Autistic doctors at work

Or how to survive the hospital corridor and other horror stories

Autistic individuals can have characteristics such as attention to detail, logical and creative thinking, genuine curiosity and a strong drive for perfectionism, traits that can be really useful in medicine amongst other professions.

Many doctors on the spectrum are believed to practice their clinical or non-clinical speciality without any major issues. Their creative problem solving skills and their strong work ethic possibly help balance minor communication problems and usually gets them through the training process. Additionally, most doctors’ clinical or non-clinical work is usually task-oriented and logical, while their role is usually very well outlined which in most cases provides the necessary work structure that most autistic individuals crave for. However, there are the ones, (and unfortunately the numbers here are completely unknown) that face significant difficulties at work.

What are the main challenges at the hospital/practice?

Lets have a closer look at the different types of challenges that autistic doctors (diagnosed or not) have to face at the hospital. I have divided these troubles into two categories: problems related to the autistic individuals characteristics and problems related to their environment. Now, I am fully aware that this is an artificial classification and therefore I feel I need to clarify that I do not intend to emphasise on what divides us, but rather detect the differences by categorising (that’s what a self respecting autistic person does) and eventually try to suggest some solutions.

Problems related to autistic doctors’ characteristics

• Sensory issues : Loud or intense sounds including the usual Friday morning fire alarm test, sensory overload in A&E where people seem to be all talking at the same time around you not considering the patients and the diagnostic procedure that is taking place in our easy to distract minds, are some of the examples of sensory issues. More specifically, I cannot be operating in theatre while there are two simultaneous and irrelevant chats going on in two different corners of the operation room. When I complain about it though I am regarded as having a ‘difficult personality’… That also goes hand in hand with my gender, but this discussion belongs to another post.

• Communication issues: Communication norms are not well understood and accepted by autistic individuals, while wording subtlety in everyday communications can become a big challenge for the autistic doctor. From exchanging an ambiguous conversation in the hospital corridor to scrutinising email replies, these situations can be really overwhelming at times and affect the individual’s mental health. For example, it took me a few years to understand that when your boss says: ‘I would probably do this if I were you’, you just have to do it, no questions asked. Of course my life would have been much easier if they would have chosen to say: ‘Please do this’ instead. These communication issues and breakdowns sometimes lead to complains from other colleagues that can make the autistic doctor’s work life even more difficult to handle.

• Social challenges: the human interactions with colleagues are a huge struggle and the rules that come with them will always be a mystery for autistic people. What is appropriate to say and when? What to wear in specific occasions? Nobody will tell you these things and there is no manual either I am afraid. You, my autistic friend, will often find yourself wondering what you have said wrong, scrutinising previous conversations that ended up in an awkward feeling or in a big question mark (what did they mean by that???) and finally often regretting everything you have said (because you can’t tell which part exactly was ‘wrong’). A big part of these social challenges has also to do with the lack of understanding and accepting hierarchical (hospital) structures. If you are an autistic trainee, for example, and your consultant says something fundamentally wrong, you won’t probably hesitate to point it out and correct them, quite often in front of others unfortunately. Now, some of the colleagues might be keeping an open mind, but in most cases the social protocol for this says ‘relationship break down’ aka no more training for you, if they are spiteful enough (it happens, we just don’t talk about it). Even though the autistic individual can be aware of the possible consequences, they often can’t help it and they will be doing the same thing over and over again. Following social cues are a struggle in general but there is a specific thing about autistics and social interactions that is especially buffing for NT people. Our face is often not exactly expressing the way we feel or think. I bet there are countless times that your teacher/professor/colleague asked you what about what they have said confuses you. Or my favourite: ‘Why are you upset/angry?’. I am not. This is just my face not following…

• Executive function difficulties: While this problem does not seem to apply to all autistic individuals, multitasking can be a struggle for some autistic doctors. This can be especially challenging for an example during a busy on call where you are often expected to handle a few things at the same times while trying to make sound decisions. Colleagues and especially consultants’ attitudes can occasionally be very military orientated and being a ‘good soldier’ is not always an autistic individual’s strong point. Not only you need to be effective (which you probably are at a very high cost) but you also have to appear effective, put together and polished, something that doesn’t usually work for autistic doctors. We are clumsy, quirky, often unable to mask our momentary struggle while the occasional ‘odd’ answer often slips out of our mouth.

• Special traits can be an obstacle: It is no secret that the drive for perfection can be a blessing and a curse at the same time. Perfectionism can be driving problems in every day functions and behaviour. For example, having to spend more time to write the perfect discharge letter while the department is extremely busy and clinical work needs to be done as well, is often not functional. Sometimes the approach required is to meet just the basic standards in bureaucratic tasks and focus more on the actual medicine (prioritisation). Autistic individuals can be hypercritical as well of themselves and of others. That, in combination with the very low threshold of getting upset when receiving criticism (constructive or not), can lead to failure of maintaining balanced and fruitful workplace relationships.

• The need of sticking to a routine can also be a huge problem at times since we autistic individuals don’t like last minute changes to our schedule. It can be very distracting and upsetting when it happens. Last minute calls to cover on-calls, late night emails with upsetting information that needs to be act upon immediately and passive aggressive text messages are not situations autistic doctors deal well with. They increase the level of anxiety and stress, leading to long term mental health problems.

Problems related to autistic doctors’ environment

In order to address this category properly, one would have to take in mind the factor of whether the autistic individual has already disclosed their diagnosis to their colleagues or not. We also need to consider that most of us keep going undiagnosed and blissfully (or not so blissfully) unaware.

• Disbelief from colleagues: When discussing the existence of autistic doctors with medical colleagues, one often hears the infamous quote : ‘we are all a little bit autistic’ Now, this is by definition not true and as an idea it certainly belittles and dismisses the autistic experience and struggles. It is usually in combination with disbelief regarding the fact that a doctor can be autistic. There are also the ones that recognise the fact that many of our colleagues are autistic, but it’s not something that is openly talked about. This culture unfortunately allows stigma and unconscious bias to contribute to poor mental health outcomes for autistic doctors.

• Inflexible structures: The hierarchical structures were created by primitive alpha males many many years ago and although this system probably still works in some ways, it does not belong to practising medicine. This ‘survival of the fittest’ narrative, especially in surgical training, is still an issue that not many dare to address. Not only does it come in contrast with the neurodiversity inclusive paradigm and adds to the stigma and shame, but it in essence consists a prejudiced and discriminating behaviour on all the levels of diversity including race, country of origin, gender and neurological subtypes.

• Neurotypicals are the majority: Nobody can deny that the definition of ‘normal’ is related to the characteristics of the mean or average, as also depicted by Bell’s curve. Therefore, the characteristics of the majority define the socially acceptable and everyone outside this has to suffer under the dictatorship of the ‘normal’. Hopefully this is a concept that has been slowly changing over the past years and I must admit I am quite optimistic about this.

What are the solutions that we can apply at work?

• Formal diagnosis. Needless to say that autism is by no means an excuse for incompetence or poor conduct. Being aware of your special characteristics and needs helps you realise not only the cause and mechanism of your troubles but also helps to take a step back and think twice before confrontation and communication break downs. It is also supposed to give you access to support and accommodations put in place to make life easier. Therefore you need a diagnosis. Not only it is freeing and gives you a feeling of belonging (finally!), but also, if you decide to come out to your colleagues it helps others to decipher or attribute your behaviours to something outside your personality, leading in this way to greater understanding, communication effort and more functioning work relationships. It is the autism to blame, you are not a bad person after all. I know it seems as a very simplistic approach but it works. Plus, people like to put others in some sort of category in order to accept them, it is a primitive and unbeatable drive. You can be different but they have to put a label on you. The coming out will also reduce the camouflaging autistic individuals use in order to appear ‘normal’, something that will have a great benefit to their mental health. We just have to keep in mind that unfortunately not all agree to go for one and also regardless of having a diagnosis or waiting in long queues for diagnosis there might be a need for immediate support and access to resources.

• Adjustments at the Hospital. These adjustments might involve changes to the working environment, the provision of specific support or redeployment. Some autistic doctors find academic or laboratory work preferable to clinical posts, but they can be excellent clinicians as well with appropriate adjustments and empathetic colleagues. Access to supportive and understanding colleagues is always helpful for autistic individuals. Team managers could also chose to assign autistic personnel to tasks and projects that play to their strengths and could therefore benefit the team.

• Provide structured work environment. Autistic individuals work better when they know what is expected from them. It could be beneficial to the departments if other doctors, especially more senior ones, could give clear instructions and set standard expectations for their autistic junior colleagues. Written communication should also be encouraged in the form of clearly written emails, instructions on paper or on the relevant electronic patient management systems (e.g. TrakCare).

• Sensory rooms. Specially allocated quite rooms/sensory rooms can be created in order for autistic employees to have their lunch in peace or to attend when sensory overloaded in order to prevent a meltdown at work. There could be provision for autistic individuals to be able to avoid loud and disturbing sounds, e.g. not to be in the ward when the fire alarm test in on.

• Creation of teams. There are recent studies supporting that autistic people generally communicate better with other autistic people than with non-autistic people. That suggests that a viable solution during wherever this is possible would be to pair two autistic colleagues together. For example, during clinical training an autistic trainee could be paired with an autistic consultant.

• Awareness and Training. Organisations and groups outside and inside the healthcare system have been recently trying to increase awareness in the community and various workplaces including the NHS. Neurodiversity paradigm is a new concept that is gradually being accepted by more and more therapists and other clinicians and is now changing our practice. Clinicians, and especially GPs who are the first point of contact when an individual seeks for a cause of their problems and a possible diagnosis, are unfortunately still using the old pathology paradigm that regards autistic individuals as broken people. They often advise people to avoid getting diagnosed in order to avoid the stigma or in some cases seem to be quite dismissing making statement like :’ we are all a little bit autistic’. In order to be able to detect something we first need to learn about it and in this case, same with pretty much every other case in medicine, ignorance is dangerous. Therefore, special courses, compulsory training modules are in order to help tackle the lack of awareness in healthcare. Organisations like the National Autistic Society are putting a lot of effort in increasing awareness in the communities and there are also recently more and more new neurodiversity groups and networks emerging in the NHS that work towards improving working and living conditions for autistic healthcare professionals.

• Mental health support. It is important that there is a system in place when things don’t really go the desired way from a mental health point of view. Autistic individuals often have mental health issues, including anxiety, depression and suicidal tendencies. There are a couple of services one can turn to when in difficulty: NHS practitioner health is is a free, confidential NHS mental health and addiction service with expertise in treating healthcare professionals. They don’t specifically deal with autism or neurodiversity in general, but they can help and support doctors that are in a crisis and can provide services such as counselling and CBT. The Doctors’ Support Network is a charity that provides confidential peer support for doctors and medical students with mental health concerns. You have to register with them first in order to access their services. The BMA also has a service in place for helping doctors and medical students working under extraordinary and challenging circumstances to look after their health and wellbeing

In conclusion, there is a lot that still need to be done in order to improve the working conditions for autistic doctors at the hospital or the practice, but the most important one we need to be focusing on is awareness. Awareness is the first step towards fighting ignorance and making the neurodiversity paradigm not only more popular in the communities, but also the only acceptable way of practising compassionate and inclusive medicine.