Neurodiversity in Medical Education (Biradar, 9/4/2024)

Deep gratitude this week to Dr. Sony Biradar for a thought-provoking Grand Rounds presentation on Neurodiversity in Medical Education. It was one of those presentations that sticks with you all day, makes you wonder if maybe you've been thinking about things incorrectly for a long time. I recommend watching the recording if you or someone you love identifies as neurodivergent OR if you work with or supervise someone who does.

A link to the recording will be available HERE.

Here are some key take homes:

• Neurotypical describes someone whose cognition is aligned with societal norms, i.e. whose brain functions are considered usual or expected by society.
• Neurodivergence describes someone whose cognition and processing are different than "the societal norm".
• Some neurodivergent people have an associated diagnosis (e.g. ADHD, autism), but not all.
• 15-20% of the population is neurodivergent 
• Neurodivergent people suffer high rates of unemployment, have disproportionate rates of anxiety, depression and risk of suicide

Dr. Biradar spent a fair amount of time talking about the idea of disability as a social construct -- first, that neurodivergence has long existed in society and may even have some developmental benefits that has ensured its persistence. In the medical model of disability (one which we are all a part of), impairments that affect one's quality of life need to be "fixed". In contrast, in the social model of disability, conditions are themselves not a disability, it is societal structures that make them disabling. 

The prevalence of neurodiversity in medical training has not been well-studied, nor has the experience of students and trainees. Dr. Biradar posits that certain adaptive behaviors/challenges may be heightened in neurodivergent trainees:

• masking: trying to hide one's neurodivergence may lead to increased exhaustion, higher rates of burnout, and even increased suicidality
• hidden curriculum (socialization that happens for trainees when what they see differs from what is said/what they are taught)
• imposter syndrome: may be increased for neurodivergent trainees
• double empathy: a type of stereotype threat. . .
• otherness: when trainees feel different from the norm, this may impact their ability to learn and perform

Dr. Biradar talked about how the process of moving through residency training-- acquiring knowledge and skills from attendings -- may simply be more challenging for neurodivergent trainees simply because the way they work/think is, by definition, different from the "medical norm". 

Residency training is known to be intense, overwhelming, and stressful. The inputs are numerous.

Experiencing this level of stress as a neurodivergent learner may be particularly overwhelming. Don't forget intersectionality,  Dr. Biradar cautions, for we know that other identities (namely BIPOC learners already experience these 

What can we do? How do we support neurodivergent learners? 

Start with being strength-based, says Dr. Biradar. Look for ways to help learners demonstrate their strengths, do not just focus on their deficits. Also, consider the theory of multiple intelligences-- different ways that learners learn and acquire new information (oral, visual, audio, reading, etc). Offer multiple options.  Promote psychological safety in your learning environment, as well as mentorship. Also encourage and promote increased neurodiversity in leadership and encourage community. 

Finally, consider the concept of compassionate pedagogy, asks us to be critical of institutional and cultural practices in medical training.  Compassionate pedagogy is a collection of teaching practices designed to foster human connection, communication, and wellbeing. The approach revolves around listening to students’ lived experiences and offering flexibility to accommodate their struggles. If we want our students to learn well, we need to honor the often imperfect way they show up. 

Dr. Biradar closed her presentation with the comic below, which captures some of the challenges of neurodivergent learners -- and the potential benefit of medication treatment for some conditions (in this case ADHD). 

References:

AoME Insights Embracing Neurodiversity in our Healthcare Educators 29 March 2023. (2023). Academy of Medical Educators.

https://www.youtube.com/watch?v=Ugx2WjkKvSI

Duong D, Vogel L. Untapped potential: embracing neurodiversity in medicine. CMAJ. 2022 Jul 18;194(27):E951-E952. doi:

10.1503/cmaj.1096006. PMID: 35851534; PMCID: PMC9299741.

Fung, L.K. & Doyle, N. (2021). Neurodiversity. The new diversity. In: Neurodiversity. From Phenomenology to Neurobiology and

Enhancing Technologies.

Goldberg H. Unraveling Neurodiversity: Insights from Neuroscientific Perspectives. Encyclopedia. 2023; 3(3):972-980.

https://doi.org/10.3390/encyclopedia3030070

Hamilton LG, Petty S. Compassionate pedagogy for neurodiversity in higher education: A conceptual analysis. Front Psychol. 2023 Feb

16;14:1093290. doi: 10.3389/fpsyg.2023.1093290. Erratum in: Front Psychol. 2024 Feb 20;14:1345256. doi:

10.3389/fpsyg.2023.1345256. PMID: 36874864; PMCID: PMC9978378.

Robinson D. Neurodiversity in medical education: How can we improve postgraduate learning for neurodiverse doctors? Med Teach.

2022 May;44(5):564-566. doi: 10.1080/0142159X.2022.2039383. Epub 2022 Mar 2. PMID: 35236237.

Shaw SCK, Fossi A, Carravallah LA, Rabenstein K, Ross W, Doherty M. The experiences of autistic doctors: a cross-sectional study.

Front Psychiatry. 2023 Jul 18;14:1160994. doi: 10.3389/fpsyt.2023.1160994. PMID: 37533891; PMCID: PMC10393275.

Syharat CM, Hain A, Zaghi AE, Gabriel R, Berdanier CGP. Experiences of neurodivergent students in graduate STEM programs. Front

Psychol. 2023 Jun 15;14:1149068. doi: 10.3389/fpsyg.2023.1149068. PMID: 37397290; PMCID: PMC10311419.

Taylor G. Editorial: Embracing neurodiversity in medicine. Aust J Gen Pract. 2021 Mar;50(3):101. doi: 10.31128/AJGP-03-21-1234e.

PMID: 33634273.

Be Curious (Jordan, 5/18/2022)

If you are interested in this week's Grand Presentations Be Curious: Cultivating Curiosity in Learners, Teachers, and Practitioners of Family Medicine, a recording is available HERE.

I will be brief with my notes:

I presented Dr. Todd Kashdan's model for the 5 Dimensions of Curiosity:

• Joyful exploration: pleasurable, knowing for the simple sake of knowing
• Deprivation sensitivity: the itch you must scratch, can be uncomfortable, even painful
• Social curiosity: interest in knowing what makes people tick
• Stress tolerance: discomfort with novelty, mystery, unknown
• Risk tolerance/thrill seeking: desire for thrill, adventure

We discussed how these different dimensions come into play in different people at different times. How curiosity is dynamic, often pleasurable (but definitely not always); how our tolerance for novel, mysterious and uncertainty play a role.

What does this have to do with Medicine?

I introduce you to the work by Dr. Faith Fitzgerald, a long time teacher and internist at UC Davis, who wrote extensively about curiosity. My favorite of her writings is a 1999 reflection from the Annals of Internal Medicine on curiosity in medical education. If you haven't read it, please do. Just click on the caption to the image below, and you will be taken straight to it. It's a beautiful piece, definitely worth your time!

Dr. Fitzgerald writes that in order to be curious, you must have 1) competence (otherwise answers fill up the space instead of questions) and 2) time. She also writes that medical education and medical practice suppress curiosity. 

To quote her further:

“Curiosity is fundamental to our physicianship, and serves both the art and the science of medicine. (How do you do? What’s your name? Where do you come from? How do you feel? Tell me more about this pain you’re having…). Curiosity is how we explore the world, this primal “wonderment” that stimulates exploration, engages both the human imagination and human intelligence. Both are integral to the humanities and science, as well as the synthesis of the two, which is clinical medicine.”

https://www.bumc.bu.edu/facdev-medicine/files/2010/09/Fitzgerald_AnnInternMed_1999_130_70_Curiosity.pdf

I also shared with you a model created by an Israeli hematologist, Dr. Shattner, in his essay from 2015 on Curiosity in medicine. His model (which I don't love aesthetically but adore in its core tenets) espouses that curiosity is good cognitively and emotionally, and it's good for patients and physicians.

You can see his model below and an updated rendition below (by yours truly)

Shattner, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484215/

And below my own rendition of his work:

As a medical educator, I am also interested in the way that -- as Faith Fitzgerald writes-- medical training can negatively impact one's curiosity. This can happen in countless ways.

Things we know suppress curiosity: haste, efficiency, fatigue, ignoring/suppressing feelings, overconfidence, rigid structures, depression/anxiety.

Ways in which teachers could enhance curiosity in the learning environment: promoting responsibility for one's own learning, welcoming diverse opinions, offering space for reflection, modelling effective management of emotions, confronting both uncertainty and overconfidence, using inquiry based learning, helping students see familiar situations as novel, maximizing small group discussions.

Are you, medical educators, using these techniques? How could you infuse the work you do with curiosity?

A final word on burnout, defined as a condition of physical and mental exhaustion pertaining to caregiving activities and arises from chronic exposure to interpersonal stressors at work. Very common in residency training, very common in primary care practice. Characterized by 3 traits: emotional exhaustion, depersonalization, and lack of personal accomplishment.

I pose this final question to you: How might we use curiosity as a mindfulness exercise to prophylax against burnout AND an advocacy tool to work toward systems changes?

Some examples:

• What happens if you are truly curious about a patient’s chronic pain?
• Or their itchy scalp?
• Or their dietary habits?
• What happens if you are curious about a surgeon’s outburst?
• Or an administrator’s edict?
• What happens if you are curious about your own wrist pain?
• Or why it is that physicians don’t take lunches?

More to come on curiosity and a proposal I have for Curiosity Rounds.

In the meantime, I encourage you all to tend to your curiosity-- it's good for patients, learners, AND for you.