The NHS and Training Programmes are inflexible for doctors who are different: This must change now.
“Anna has openly shared in a variety of settings her mental health difficulties. This has led me at times to be concerned about her welfare and her fitness to practice as a doctor.”
As I read this feedback on my portfolio, which the ARCP (Annual Review of Competence Progression) panel would have reviewed and considered the next level of my career progression, it made me wonder about the safety of doctors’ honest disclosure of their challenges for “being different” to their peers and senior colleagues. This includes the challenges with their physical and mental health, as well as being of different racial origin, being neurodiverse or belonging to the LGBTQ+ community.
I can only apologise for making people uncomfortable as an autistic individual. However, I wouldn’t have known that I was making people uncomfortable unless someone had told me. For 32 years I have never exactly “fitted” along with anyone. I had made unreasonable adjustments for myself to have myself work within the neurotypical world. Once I received the diagnosis, I felt I was finally liberated to be myself with no shame. Coming forward with my diagnosis means I can be proud to be who I am.
Now, after reading these comments, I am not so sure.
I am a Core Trainee Psychiatrist, passionately advocating for human rights and mental health. I am part of the executive committee for the Royal College of Psychiatrists’ Women’s Mental Health Special Interests Group. I am a leader of Geopsychiatry, an NGO (non-governmental organisation) which studies the impact of war conflict, climate change, public health issues, globalisation and foreign policy on mental health. I have written articles, such as the need for women's leadership in the UN, and how COVID-19 unmasked the ongoing pandemic of gender-based violence.
In my previous blog, I had written about the gender gap in our training I have now become more aware that it is not only a gender gap in our training. There is also a gap in addressing racial inequality and neurodiversity in our training, especially when the feedback of our colleagues is captured in the Multi-Source Feedbacks (MSFs).
As I read the above feedback comment again, it reminded me of a book called “Beneath the White Coat: Doctors, Their Minds and Their Mental Health” edited by Clara Gerada. This book explored the growing mental health crisis among medical professionals, examining the secrecy surrounding doctors with mental illnesses and highlighting the limited resources available to them. This book is a reminder that mental illness is still stigmatised today.
In the Psychiatry field, we applaud doctors coming forward about their mental illnesses and their struggles. However, behind the scenes, we do not know the stigmatisation, the challenges and the lack of empathy they faced.
Were these doctors questioned on their fitness to practice? When the doctor did seek support via therapy and mental health services, was their training delayed because supervisors said that they were currently using mental health services, and were therefore not “fit” to progress further in their career and fitness to practice?
You would think this doesn’t happen, but the book, other peers’ stories and personal experiences have informed me that this is all too common.
Have we been too gullible to believe that our colleagues and supervisors cannot be discriminating against other doctors for just “being different”?
“To establish and maintain good partnerships” with everyone in the organisation (patients, teams, peers and senior colleagues) is extremely exhausting for autistics; I can imagine it is just as tiring for other neurodiverse doctors as well.
In a survey, 1% of general practitioners and 1.1% of psychiatrists identified as autistic; alongside the general UK population figures of 1.1%, this means at least 3000 UK doctors are likely to be autistic.
Autism is already subject to employment law regarding associated disabilities. However, autistic and many other neurodivergent doctors are too often not able to achieve their potential due to misunderstanding stigma, under-recognition or lack of reasonable accommodations.
Autistic doctors tend to speak out against injustices — for example, unsafe patient care or staff mistreatment. As an article in the British Journal of Psychiatry had recently written: along with the risk of being misinterpreted and marginalised, when policies have been followed on raising issues in regards to patient safety concerns or other “high risk” issues, autistic doctors are described as “trouble-making, lacking team skills and confronted for being unprofessional…”
Therefore, undiagnosed and unsupported autistic colleagues may sometimes present as “doctors in difficulty”.
Looking at again the comment on my portfolio, I do wonder if some of my colleagues, whom I thought understood and empathised with my disability and mental illness, used it as reasons to halter my career progression and cast doubt on my profession.
Some might argue that my colleagues were genuinely concerned about my mental health and my disability, as reasons to question my fitness to practice.
However, I believe many doctors aren’t aware of the GMC Standards and Guidelines for Welcome and Valued: Supporting disabled learners in medical education and training.
The GMC has recognised that doctors can experience ill health or disability throughout any point of their careers, and having a health condition or disability alone is not a fitness to practice concern.
Reasonable adjustments and support are required to remove the barriers individuals will face, in line with equality legislation. At a personal level, I want to emphasise that the GMC’s guidance specifically recognises that transitions during training can be challenging for doctors with disabilities, including those with an autism spectrum disorder.
The Royal College of Psychiatrists Equality Action Plan
In January 2021, The Royal College of Psychiatrists released the Equality Action Plan, led by the Presidential Leads Dr Shubulade Smith and Dr Rajesh Mohan. The Equality Action Plan aims at promoting equality and equitable outcomes between 2021–2023. This includes opposing all forms of discrimination, delivering equity of opportunities for all members of the College, as well as encouraging all doctors and students from all backgrounds, to be supported and encouraged to become members.
The RCPSYCH Equality Action Plan aspire to an approach known by the acronym CIRCLE: Courage, Innovation, Respect, Collaboration, Learning and Excellence. Furthermore, autistic doctors have come forward to be acknowledged and included in the RCPSYCH Equity Action Plan, to seek collaboration in regard to specific support and adjustments. As Sue McCowen and Mary Doherty had written in a BJPSYCH article: A diverse workforce is a well-rounded workforce and a full CIRCLE.
The NHS and Training Programmes are meant to encourage trainees to be themselves, in order to enrich our culture with diversity, inclusivity and equity. However, the feedback and the assessments we send to complete our training portfolios may be used as “tools” to discriminate and harass victimised trainees under the guises of terminologies (such as competencies and probity), as well as impair their careers — thus, widening the gap in gender, sexuality and race.
Personally, as an autistic woman of colour who has passion, and an advocate for justice and human rights, I have been made to feel ashamed of being who I am.
We are constantly reminded that we do not come to work for NHS to be abused and discriminated from those who we are treating.
However, do we have to tolerate the abuse and discrimination from our colleagues, supervisors and line managers? Where and with whom can we feel safe to work to ensure the best clinical practice and patient care, if we do not feel safe in our environment and with the people we work with? The culture shouldn’t be “us alike versus them not alike”, instead it should be “all of us”: all specialities in medicine will advance in every aspect if we allow diversity and equity to thrive.