Background

With the recent publication of the Royal College of Psychiatrists’ Equality Action Plan 2021–2023, we welcome the promotion of equality, diversity and inclusion.¹ Members of the College also aspire to a values-based approach known by the acronym ‘CIRCLE’: Courage, Innovation, Respect, Collaboration, Learning and Excellence. Although the College welcomes the whole workforce within its Equality Action Plan and CIRCLE values, we ask for autistic doctors to be acknowledged and included, seeking collaboration regarding specific support. We are aware that other neurodivergent doctors may also wish to highlight their own needs. The College is well placed to lead the way on neurodiversity and it would seemingly be the first Medical Royal College to formally recognise and support neurodivergent doctors within policy. A diverse workforce is a well-rounded workforce and a full CIRCLE.

In surveys regarding identifying and supporting autistic patients, 1% of general practitioners and 1.1% of psychiatrists identified as autistic .^{Reference Crane, Davidson, Prosser and Pellicano2} Alongside general UK population figures of 1.1%, at least 3000 UK doctors may be autistic . It is likely to be far more, however, given that medicine, and psychiatry within it, selects for many autistic strengths,^{Reference McCowan, Shaw, Doherty, Grosjean, Blank and Kinnear3} and that non-stereotypical profiles are still underrecognised by individuals and clinicians. It seems a relatively new belief that autistic doctors even exist and can be good clinicians, supervisors and educators, yet we have been here all along doing just that, with or without the diagnostic label. In the peer-support group Autistic Doctors International (ADI), 13% of members were psychiatrists in the last poll, second only to general practitioners.^{Reference McCowan, Shaw, Doherty, Grosjean, Blank and Kinnear3}

Autism and employment law

Autism is already subject to employment law regarding associated disabilities but we know from peer-support groups that we, and many other neurodivergent doctors, are too often not achieving potential because of misunderstanding, stigma, underrecognition or lack of reasonable accommodations. Psychiatrists may remain cautious when considering disclosing autism, with the real risk that professional credibility may be questioned. Promoting open discussion and a culture of acceptance may encourage disclosure and better access to workplace-based adjustments, which are likely to improve well-being, resilience and retention. These are all priorities for our National Health Service workforce.

Recognising strengths and attributes

It should be noted that issues faced by autistic doctors are mostly non-clinical. Challenges more often relate to the largely non-autistic workplace set-up and to what can, at times, be confusing communication with colleagues or management. Autistic people tend to communicate better with other autistics and non-autistic people with other non-autistics. When the two neurotypes communicate with each other misunderstandings are more likely to occur, so both need to make an effort and not solely the autistic person. Most of us are not ‘doctors in difficulty’ and do not fulfil autistic stereotypes. This risks autistic strengths and successes going unseen, fostering a deficit-based view and facilitating the ‘tragedy narrative’ that too often surrounds a diagnosis. The neurodiversity paradigm fits our experience of autism as a different neurotype with many strengths, rather than pure disability or disorder, and challenges stigma, which remains pervasive throughout healthcare. The narrative we project about neurodiversity within the workforce is mirrored in our interactions with patients and their families, which can profoundly and positively influence their own perceptions and outcomes.

Specifically acknowledging and supporting us within the Equality Action Plan also sets the expectation that we should consistently experience the College's values in the same good faith in which we practise them. Many autistic attributes are naturally aligned with these CIRCLE and core values (in italics in the paragraphs that follow).

We have demonstrated the Courage to continue as doctors despite feeling somehow ‘different’ from an early age. We have sustained self-belief, resilience and a growth mindset, despite the pain of our credibility and worth often being subtly or overtly challenged. We have an empathic Respect for others, often grounded in our own experiences of being outsiders. We Collaborate, finding ways to work with others to further shared goals, tenaciously Learning and Innovating as we have had to copy, analyse and then experiment with social communication since childhood, changing variables until success is achieved. We tend to ‘think outside the box’ and instinctively aim for Excellence as we hyperfocus on intense interests, which usually include our work. Our autistic strengths include self-motivation, curiosity, pattern recognition, attention to detail and problem-solving.^{Reference McCowan, Shaw, Doherty, Grosjean, Blank and Kinnear3}

Contrary to outdated stereotypes, many of us have increased empathy and, as such, have tended to gravitate towards the caring professions. We are aware of our position of trust and as a group have a tendency to speak out and strive for social justice – for example, unsafe patient care or staff mistreatment. Such actions are grounded in our prevailing sense of honesty and fairness. However, this comes with a risk of being misinterpreted and marginalised. As we often precisely and literally follow policies on raising issues we risk being misunderstood as trouble-making, lacking team skills and confronted for being unprofessional, without seniors considering that unspoken non-autistic rules of finding another way may not have ever been made clear.

There is an autistic tendency to value all people equally, sometimes speaking plainly and without hierarchical restriction, which should not be mistaken for lack of humility. We strive to uphold the dignity of both our autistic patients and colleagues. This can be a difficult path to tread as recognition and understanding of autism is still evolving for many professionals. However, we embrace opportunities to inform education and training with lived experience, and challenge stigma through the positive promotion of neurodiversity. In the workplace, as in life, autistic people are different, not less. We respect that our non-autistic colleagues communicate differently and ask for reciprocity regarding our different communication style.

Equity

The Foreword to the Equality Action Plan states that ‘Discrimination and prejudice, based on any of the protected characteristics, is inherently wrong and can lead to profound distress and unhappiness, which negatively affects mental wellbeing’.¹ We certainly agree with this and note that ‘camouflaging’ or ‘masking’ (hiding autistic features) is associated with increased anxiety, depression and suicidality.^{Reference Cook, Hull, Crane and Mandy4} With high rates of burnout, mental illness and suicide in both doctors and autistic adults, the consideration and support of hidden autistic doctors is vital. For those of us who managed to facilitate accommodations without knowing why, this has typically been at our own expense, often accompanied by unnecessary shame and low self-esteem, alongside a potential adverse impact on health and earnings. Specialist assessment may be helpful to recommend a range of adjustments that we cannot always identify ourselves. Equity is a better approach than equality, as different people need different supports. We do not all need ear plugs, for example. However, some may not manage a working day without them.

Support and signposting

Undiagnosed and unsupported colleagues may sometimes present as ‘doctors in difficulty’. It is, therefore, worth considering whether students and doctors with a variety of challenges might be unknowingly autistic. These might not be well-recognised autistic challenges but may include areas such as unfulfilled potential, spikey profiles (a large differential between strengths and challenge areas), communication issues with colleagues, time management (which could instead be transition issues), a perception of not being ‘flexible’, not sustaining work without repeated absences, and not benefitting as much as expected from the usual support offered. As supervisors or mentors, the College asks us to help colleagues to fulfil their full potential in carrying out their clinical and other responsibilities at work. Many are already on the way to achieving some of this naturally, in a person-centred manner, without realising that they are interacting with autistic doctors. However, understanding of autism and consistency in approach is needed for all autistic doctors. While respecting differences, appropriately experienced support should be sought, including signposting to peer support, such as that offered through ADI.^{Reference McCowan, Shaw, Doherty, Grosjean, Blank and Kinnear3}

Perceptions that autistic doctors are automatically unsuited to their careers still occur in various specialities, alongside adverse feedback without relevant help or workable, specific suggestions. One member who disclosed was simply told in writing that autism is incompatible with being a doctor.^{Reference Doherty, Johnson and Buckley5} Support from ADI, such as letters or attending fitness to practice meetings, has changed outcomes by informing, explaining and challenging out-of-date beliefs. Once implemented, we have seen examples within ADI of autistic doctors continuing their careers and thriving. The real risk of losing one's credibility and job is why many experienced and successful autistic doctors may not seek or disclose a diagnosis and fear requesting reasonable accommodations. One of our authors is using a pseudonym for these reasons. It is therefore vital that we are specifically included in the Equality Action Plan.