Neurodiversity is the term used to describe the wide differences in the interactions and experiences that individuals have with others and the world in general.¹ The term encompasses specific conditions including autism spectrum disorder and attention deficit hyperactivity disorder (ADHD). Specific learning difficulties (SpLD), including dyslexia, dysgraphia, dyscalculia and developmental coordination disorder (dyspraxia), describe differences in the ways in which an individual interacts with and processes information that affect different aspects of learning.²

In 2018, the General Medical Council published Welcomed and Valued,³ a document laying down an advisory framework for supporting individuals with disabilities including SpLD and neurodiversity in medical education and training. As this document highlights, there is a requirement to comply with UK equality legislation and also with GMC standards for medical education and training.

The pathology trainer’s perspective

Dr Liz Hook is a university lecturer in cellular and molecular pathology and an honorary consultant paediatric pathologist at Cambridge University Hospitals NHS Foundation Trust. She is the senior examiner for clinical pathology at the University of Cambridge and, having received additional training in facilitating learning for students with ADHD and SpLD, works closely with medical students with ADHD and/or SpLD to support their studies.

Why is this for trainers and programme directors?

In higher education, the number of students with a diagnosis of SpLD and/or neurodiversity is increasing.^4,5 Best practice now entails promoting early diagnosis of these conditions. Institutions are encouraging students to undergo educational/ learning assessment if potential issues are identified. Diagnosis of an SpLD and/or neurodiversity is then followed by the adoption of reasonable adjustments in learning and examination environments to afford equity by removing barriers that disadvantage the individual owing to their condition. Examples of reasonable adjustments include additional time for assignments, 1:1 coaching from a trained professional, early access to teaching material and variations in examination conditions.

...diagnosis alone is not sufficient and appropriate support needs to be offered after this, including targeted educational input to identify areas that the individual finds especially challenging.

Doctors in training who find the FRCPath examinations challenging may have existing or undiagnosed SpLD and/or neurodiversity, which can be subsequently identified on assessment.

Early assessment and support are best encouraged by increasing awareness among trainers and doctors in training, by local signposting and with easy access to assessment, usually via local Health Education England (HEE) Deanery Professional Support Units. However, diagnosis alone is not sufficient and appropriate support needs to be offered after this, including targeted educational input to identify areas that the individual finds especially challenging.

In my opinion, in addition to standard neurodiversity/SpLD coaching, input from a subject matter specialist who has received training in supporting learning for individuals with neurodiversity and/or SpLD may be beneficial. In particular, such trainers can provide specific insight concerning approaches to assessments.

Why is neurodiversity important to the College?

Key considerations for the College about training and assessment for individuals with SpLD or neurodiversity focus on curriculum and assessment design, including the consideration of reasonable adjustments, a role highlighted in Welcomed and Valued.³ Ideally, however, widespread adoption of universal design for learning would ensure that teaching, training and assessment are accessible to as many as possible. The principles of universal design for learning focus on creating inclusive teaching and environments that remove as many barriers to learning as possible.⁶ 

The College’s involvement in both training and workforce means this is a highly pertinent issue. The provision of pathology discipline-specific advice for trainees, trainers, programme directors and ultimately clinical directors could move the College to the forefront of ensuring equity across the workforce for individuals with SpLD and neurodiversity.

The current model for consultant appointments requires individuals to negotiate any reasonable adjustments required with their clinical leads and occupational health departments. An advisory guide provided by the College suggesting recommendations for workplace accommodations could suggest a supportive blueprint of reasonable adjustments and an evidence base for individuals to negotiate with their local employers.

The starting point for this process should be supporting members who have an SpLD and/ or neurodiversity to talk with the College about their experiences in the workplace and highlight both helpful adjustments and also aspects of the workplace that remain challenging.

Why is this important for the consultant workforce?

Increasing recognition of SpLD and/or neurodiversity in medical student cohorts^4,5 will be mirrored across the medical workforce over time. Provision of supportive and appropriately adjusted working environments may lead to reduced consultant burn-out and improved job satisfaction and, thus, retention of individuals within the consultant workforce.

Suggestions for development

The College has already made a number of positive changes with the commissioning of a strong Equality, Diversity and Inclusion Network by the Trustee Board and the hosting of informative events such as the recent webinar panel discussion Improving disability adjustments in pathology: current perspectives and looking to the future. However, there is more to be done and I would make the following suggestions to encourage open discussion on this important topic.

Regarding training, information about SpLD and neurodiversity and how to seek support and assessment should be provided on the College training pages.Ensuring identification and dissemination of excellent practice across different training programmes could be achieved via the Trainees Advisory Committee. Universal design for learning principles should be applied to curricula, assessment and workplace standards.⁶

In Welcome and Valued, ³ it is suggested that reasonable adjustments should be reviewed to ensure that the desired results are achieved; if an adjustment is declined, the suggestion is made for an audit trail to be kept to give evidence of decision making. For high-stakes situations around assessment, this might be best achieved with a multidisciplinary review committee.

Finally, visibly demonstrating that everyone is welcomed and valued within the UK pathology community will benefit our workforce as a whole. The contents of this article have been shared with the College Learning directorate, which will consider the various suggestions raised.

The trainee's perspective

Dr Rachel Rummery is an ST6 trainee in paediatric and perinatal pathology at Yorkshire and the Humber Deanery. She is also the current Vice-Chair of the College Trainee Advisory Committee.

Personal experience of neurodiversity as a trainee pathologist

After Liz’s experienced insights into the overarching organisational importance of neurodiversity and SpLD, it falls to me to give my personal view of their effects. I have no expertise in this area and my thoughts can only reflect my own experiences.

I have had an eclectic career. I did my undergraduate medical training at the University of St Andrews, then Trinity College, Cambridge. I was a pathology lecturer and honorary registrar in the 1990s, then took a career break to look after my children before returning to medicine in 2011. I re-entered the histopathology training programme in 2013 and moved to paediatric and perinatal pathology after my FRCPath Part 1.

Wanting to use my experience of returning to medicine (which wasn’t easy) to help others, I became one of the inaugural Health Education England (HEE) Supported Return to Training fellows in 2018. Then, alongside training, I became the HEE Clinical Lead for Return to Practice (see Dr Rummery’s article on this in the April 2020 Bulletin). In this role, during the pandemic, I worked with NHSE/I on the Bringing Back Staff initiative. I also instigated the launch of the HEE CaReForMe return programme⁷ and worked with the General Medical Council to produce the Completing the Picture survey, the world’s largest study of why doctors leave medicine.^8,9

The difficulties that neurodiverse trainees can face

The relevance of this career path is to highlight how hidden neurodiversity can be. Until my ST5 training year, there was no reason for either me or my trainers to consider that I might have any SpLD or neurodiversity. I had never failed an exam or had less than an ARCP outcome 1. However, as my FRCPath Part 2 exam approached, I realised, as I looked at the various elements, that I was going to find the format very difficult – or if I was honest with myself – impossible.

In many ways, my diagnosis has been nothing but positive.

Initially, I was concerned I would not be able to write fast enough, so perhaps I had an element of dysgraphia. I took a deanery-approved screening test, which instead highlighted working memory, processing speed and attention issues. I then had a formal educational psychologist assessment which diagnosed dyspraxia (developmental coordination disorder) and probable inattentive attention deficit disorder (ADD).

In many ways, my diagnosis has been nothing but positive.

I realised, as I looked back through my life, that it explained so many things: the annual school reports that were all variations on a theme of ‘able but slow and a bit lazy’; my inability to take minutes or lecture notes (I bought the textbooks); and why I found writing long reports (including scientific papers) very hard, especially in one sitting – I tended to break work down into manageable chunks.

On a personal level, it explained apparently trivial things like why I take a long time to cross the road (I process the speed of traffic slowly), and why I can’t follow board game rules (my working memory is too poor) or play fast-paced computer games (my processing speed is too slow). Physically, I’ve never been able to play team sports, kick or catch a ball and I still have an odd way of tying my shoelaces. The realisation that my various difficulties are not laziness has finally allowed me to be kind to myself.

The impact of support

So, I didn’t doubt the diagnosis was correct, but it was still a shock. I’d barely ever heard of dyspraxia or ADD/ADHD. I’ve always been a very independent person, so I found reaching out for help hard. But I did ask for help and I got it – in spades! I have had truly stellar support from my educational supervisor, mentor, trainers, deanery, sub-specialty exam panel and colleagues in the College. I am on the Equality, Diversity and Inclusion Network and was a panellist in the webinar that Liz mentioned above.

My deanery has provided neurodiversity coaching and time for mentoring, all of which have been very useful, providing insights that are useful not just for training but for future working, making me more efficient and confident.

The hardest thing to come to terms with has been the gradual realisation that, while understanding, support, coaching and self-compassion are all incredibly useful, they cannot ‘fix’ me.

The adjustments I need in my working day are actually very minor – report templates, a desk that faces the wall, noise cancelling headphones, voice recognition and a chair for post mortems/surgical cut up. But they have made a massive difference.

I am also more aware of my strengths. A lifetime of unconsciously using my perceptual reasoning and verbal comprehension to compensate for my working memory and processing speed means that, like many neurodiverse people, I enjoy outof-the-box and big-picture thinking, something I have found very useful in my leadership roles.

The hardest thing to come to terms with has been the gradual realisation that, while understanding, support, coaching and self-compassion are all incredibly useful, they cannot ‘fix’ me. I cannot change my cognitive profile. It is as much part of me as a more physically manifested disability.

This means that, after three attempts, I have so far been unable to pass my Part 2 exam, although I have passed all the elements at some point.

Liz is right that awareness and acceptance are key. I very much wish I had known earlier. Hopefully, sharing my story is a small step along this road and will help others. I wish to thank the College for being so proactive in engaging with this topic, and Liz for so generously giving us the benefits of her expertise.

References available.