April is now referred to by many as Autism Awareness Month. Many of us in the Autistic Community would prefer it was called Autism Acceptance Month; people seem adequately aware of autism these days, but acceptance is often lacking.
I want to address something that is both an issue around awareness and acceptance. Having recently been the subject of a number of media articles that highlighted the fact that I am a doctor and also autistic, I was faced with certain comments and assumptions. The one below is worthy of discussion.
“Am I alone in thinking that autism is not compatible with seeing patients? Surely empathy is essential in a medical practitioner but this is by definition lacking in someone with autism?”
My immediate response to this comment was an internal monologue along the lines of “No, sadly, you are not alone in that thinking… But, you are wrong.”
Let’s talk about empathy, and then let’s talk about that in someone who is autistic.
Autistic people do not lack empathy: This is an age-old myth that is harmful and quite lacking in insight! Empathy is the ability to understand and share the feelings of another; it relates to how good we are at sensing another person’s emotions and understanding what they are thinking or feeling. Breaking it down, there are multiple parts to empathy:
- Sensing what someone else is feeling (distress, happiness, anger)
- Understanding what another person is thinking or feeling (being able to put yourself in their shoes, having theory of mind)
- How a person visibly responds to emotions expressed by those around them (perhaps you reach out and hug someone who looks sad).
Other forums might describe the two different types of empathy; Affective empathy and Cognitive empathy. The first, affective empathy, refers to the sensations and feelings we get in response to others’ emotions. The second, cognitive empathy, refers to that ability to identify and understand another person’s emotions by taking their perspective.
There is good evidence that autistic individuals do have a strong sense and awareness of the emotions expressed by others. Often a heightened sensitivity to the emotions of others is something that overwhelms autistic individuals. Now consider the role of affective empathy in medical practice; it is the feelings we get in response to others’ emotions: We see someone sad, so we feel a bit sad. We may see someone is fearful and become fearful too. Often the role of affective empathy isn’t to ‘fix’ something driving another person’s negative emotion (if it is negative), but to ‘convey’ to that person a degree of understanding so that they feel heard and understood. Consider that in the context of a doctor treating a patient. If my patient is highly distressed about their illness, I would prefer that I not mirror that high level of distress, automatically. It is important that I understand they are distressed, and why that is likely (cognitive empathy, which we will come to), but there is little benefit in me mirroring their distress beyond communicating that I do have an appreciation of their predicament. To be honest, the ability to not become enveloped by the emotions of those around, when faced with highly distressing scenarios can be an advantage; perhaps it allows you to step back and focus on finding a solution to the distressing situation, perhaps you can calmly handle a pressing medical emergency.
Please don’t assume I’ve never cried with a patient or family member: I have. When it has been appropriate, I have sat with patients or their loved ones and cried, laughed, and celebrated.
Cognitive empathy is something we learn. It is a developed social skill. It is true that autism is a developmental disorder and that many individuals who are autistic need some extra assistance in developing certain skills, including theory of mind and cognitive empathy. The point is, cognitive empathy is something you can be taught, and you can choose to develop in yourself. Perhaps more than many of my neurotypical peers, I have specifically worked on my own skills in cognitive empathy (from quite a young age) after realising it didn’t come naturally.
Here is an example of how age, and experience can impact on an autistic individual’s cognitive empathy.
At the end of 5thgrade, in primary school, I recognised that my teacher had clearly struggled having me in her class for an entire year. I was pretty advanced in mathematics but struggled with the nuances of language. My teacher was amazing with language, but not quite so strong with basic maths. I had affective empathy; I realised she felt stressed whenever she needed to teach what she considered ‘difficult mathematics’. What was lacking was my cognitive empathy. By nature, I am extremely caring, and I thought I should try and help my teacher so she wouldn’t feel so stressed the following year. While we hadn’t managed to get along for most of the school year, I decided I would offer her a solution to her woes on the second last day of the year. During recess I approached her and said the following:
“Ms Brown (name changed). I’ve been thinking about how you could have a better year next year. I know you’ve found the maths quite hard while teaching grade 5. Maybe next year you could teach Grade 2; then the maths and the English will be at your level and you won’t have to feel stressed.”
As an adult, with developed cognitive empathy, I both cringe and laugh at that statement. It was said with the best of intentions and I was quite shocked at the absolutely volcanic response it received at the time. Now, I understand how offended a grown adult would have been having an eleven-year-old suggest they were only capable of Grade 2 maths. I only attended that school for one more day and then my parents moved me.
Life experience, social stories and lots of practice mean that I have a reasonably strong cognitive empathy capacity now. No, it isn’t always natural. It doesn’t matter that it isn’t. It is a bit like having to have learnt another language to communicate in. I simply have to make the decision to think through a situation and actively consider what the other person’s perspective may be in any situation. As with any other learnt, unnatural skill, it is more likely to ‘fail’ when tired or sick. For many people with a second language, they prefer to use their native language when tired; that doesn’t mean they can’t be extremely proficient in the use of their non-native tongue.
The development of cognitive empathy is foundational to responding in a socially acceptable manner. A socially acceptable response can also differ depending on who you are responding to. Having invested into my own cognitive empathy abilities I am relatively confident that, in the majority of situations I can display an appropriately empathetic response to a patient or family member in a clinical setting. After all, I never saw medicine as simply knowing a bunch of facts about physiology/pathology/anatomy; medicine is about helping people. When I am with a patient, I see making an assessment of how they are feeling and responding as much a part of my job as interpreting their blood work or chest x-ray. Because it is, to me, part of my role as a doctor, the cognitive empathy side of an interaction is something I actively consider and plan for.
I have never had a patient complain about my level of empathy. I have had a multitude of patients convey to me their gratitude to have been treated by someone that clearly stopped and considered their emotions and perspective; this is a far cry from the inference that an autistic doctor lacks empathy.
Being autistic, I often watch the same movies over and over again. In high school I watched the movie “Patch Adams” so many times that I can literally watch the movie in my own head with all the scenes and script lines perfectly recorded by my own memory. In my first year of medical school the walls of my college bedroom were plastered with quotes from the movie “Patch Adams”.
“If you treat a disease, you win, you lose. You treat a person, I guarantee you, you’ll win every time; no matter what the outcome.”
“What’s the difference between a scientist and a doctor?… … People!”
“If you focus on the problem you can’t see the solution.”
Simply having that obsession with “Patch Adams” before I even commenced medical school was a strong foundation in ensuring I developed cognitive empathy alongside all the other requisite skills taught in medical school.
Finally, we need to think about the response we exhibit once we’ve identified emotions in another person and considered their perspective. Every person is different (and that’s a good thing). Some people will show they care by reaching out and hugging someone who is distressed. Another person may walk away to go hunting for a solution to whichever problem has caused that distress. We need both of those kinds of people! There is nothing wrong with being the hugger. There is nothing wrong than being the person who takes on board that someone is distressed and then walks away to try and find a solution. Hopefully, the ‘hugger’ and the ‘solution hunter’ are paired together within a team, giving a distressed patient the best of both styles. They are also not mutually exclusive. With enough time available, a single individual can offer both responses.
Personally, I am the ‘solution hunter’. When I see a problem that is causing distress, I want to get to the root cause of that issue. I’m that person that will be trawling through countless books and journal articles trying to come up with a creative and effective solution if there isn’t one that is immediately obvious. I am the one whose mind won’t shut down while they’re eating dinner at home until I’ve solved that problem. That’s my strength. I can be the one to sit there, listen and be a shoulder to cry on; but I am much better at being the invisible solution finder. Heading off to the library to try and find a solution to your patient’s problem is no less empathetic than sitting there and holding their hand while they process their own emotions.
The ultimate positive of being an autistic doctor is that I have had to learn cognitive empathy and practice taking the perspective of a lot of people who think quite differently to me. But there have been times when I have been the only doctor able to take the perspective of certain patients; my autistic patients.
I have had autistic patients who have struggled with the same things I struggle with when I am in that patient role. Sensory issues. Food preferences. Difficulties in a different environment. All of these things impact on patients, and particularly autistic patients. It amazed me while working on one unit that my entire team were quick to criticise how challenging one of our adult autistic patients was. To me, it was completely logical. The young man was in a 6-bed bay, in a state of sensory overload, and being denied access to his usual coping mechanisms. The need for a ‘psychiatric consult’ vanished overnight when I implored the nursing team leader to implement some minor changes to his location and how nursing staff were approaching him. With this patient, my own natural ability to understand what was causing him difficulty was superior to that of my neurotypical colleagues. While they are more able to naturally relate to the perspectives of other patients, they struggled with their own cognitive empathy skills when faced with a neurodiverse patient.
In concluding I’d ask the following. If you are a doctor, or health professional, consider what I’ve written before you criticise yourself or a colleague on their ‘empathy’ skills. We are all different and we have patients who are all different. Your way of expressing empathy may differ to the doctor sitting next to you; neither one of you is better. You may be ‘better’ for Patient X in Bed 1 and your colleague may be ‘better’ for Patient Y in Bed 2. Instead of criticising when someone responds differently to how you would, consider it a blessing that we have peers who are able to think differently to us and who have different strengths to our own; because when we team up, we are able to offer a broader level of support to the patients we come across.
The Good Doctor 
I am an allied health professional and I am certainly empathetic to your cause. If you have the ability to become a doctor you certainly should be able to see patients. The issue is, no one knows really and little or no evidence. It is just easy way is to say no. I wish you luck and there are more people on your side that you may think. Regards, Casper Ozinga, Walcha NSW
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Thank you. 😀
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Medicine has got a lot of neuro divergent doctors . They all have been able to function well seeing and treating patients . This new wave of “adult autism diagnosis” is just another wave .
In my opinion , people have traits and that is it .why do some people want to call it autism ? …the answer is “to exclude “ .
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Best wishes with the de novo hearing.
Coincidentally, I recently completed my annual CPD for lawyers. This included one unit on mental health in the profession. Part of that focussed on the law in Australia about entitlement to practice after earlier history of medical or mental impairment. In short, it is established (for the legal profession) that past history is no automatic bar to future entitlement to practice.
If the health tribunal applies similar principles to your case, then you could benefit.
On your theme of “empathy”, there’s more to optimum medical care than the squishy emotional “empathy”. Also recently I suffered an appointment with a medical specialist who was new to me. In short, after a battle where I struggled to get her to look at the details of the history and to discuss details of results, and I reminded her why I was there, having sent in the referral a week before and called months before, she lost her patience (and patient!) and said she was a good specialist because she had empathy with her patients.
I said I did not want her empathy, only for her to listen, take into account what I said and work with me.
I have abbreviated the sorry saga, of course, but in the entire wasted effort it came down to her validating her contribution to me based above all on her empathy with her patients.
I did not want empathy.
I wanted science based, personalised medical care, based on facts and discussion.
Have you considered that you might be an even better specialist than a GP?
If you were specialising in the field which I need, then I would travel interstate to give you a go!
PS, to chide in a spirit of uplifting your self-esteem:
Autism is not a developmental disorder. It refers to a spectrum of traits that are normally occurring over time in populations which is untypical only by reference to the numbers within the entire population. I do not mean to be pedantic – just to help you see that you do not have disorder. Being who you are is normal in a population.
You are not an autistic doctor. You are a doctor with some autistic features and a lot more.
They are not autistic patients. They are patients with some autistic features and a lot more.
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Thank you for your kindness. Do you have a reference for it being established in the legal profession that past illness etc can’t stop you practicing? Case law would be most helpful, but any reference would be appreciated.
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Part One
The particular CPD session was authored by Michelle Sharpe.
From her bio for the course, some excerpts:
“Dr. Michelle Sharpe is a member of the Victorian Bar practicing in general commercial, consumer protection law and administrative law.”
…
“Michelle is the founding member and former chair of the Victorian Bar’s Health and Wellbeing Committee. During her 9 years on that committee Michelle helped to establish a wellbeing program which included a 24/7 counselling service for barristers. This program was a finalist for the Australian Psychological Society Health and Wellbeing Award for 2015. Michelle has also given papers and written publications on the subject of mental ill health in the legal profession.”
You might get a copy of her latest paper on this topic (search for her at her chambers).
(I believe that my very limited except below does not infringe copyright. All credit to Dr Sharpe for writing on this topic.)
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Part Two
For the benefit of others, I stress that the case law on the tests for lawyers depends on the law applying to them, and as at the applicable time. This might differ from the law applying to doctors.
I cannot say anything about the test(s) applying to Dr Taylor’s current case.
Also, I have not found anything about whether or how autistic traits ought to be considered an impairment. The tests for lawyers usually revolves around some concept of “fitness” (among other criteria).
So, my response is about the cited cases for the topic of readmission after some history of impairment or unfitness which the applicant submits no longer applies.
Dr Sharpe points out that the law for Victoria and for NSW changed when they both adopted a uniform law in 2015.
So, even for the tests for lawyers you have to be careful when reading the judgments about what law was at the time of the cases for those judgments.
Here are the three main cases cited by Dr Sharpe.
Legal Profession Complaints Committee v A Practitioner [2010] WASC 13
See paragraphs 25 and 26 for principles and citations (for striking off in this case, but still relevant to a later application for readmission).
See especially paragraph 27:
“27 Although the tribunal made no finding to this effect, it seems a reasonable inference from the materials before the court that the practitioner’s conduct was closely associated with the psychiatric conditions from which she suffers. Those conditions create a degree of risk to the public, in the event that the practitioner was permitted to remain in practice, which is unacceptable. However, should those conditions and the symptoms associated with those conditions subside, it is not beyond the realm of possibility that the practitioner might be readmitted (Re Stokes [2008] WASC 269). That prospect might provide some incentive to the practitioner to undertake the treatment regime which has been proposed for her. Only time will tell whether the practitioner’s condition will improve to the point where readmission could be contemplated.”
This also endorses, without qualification, Re Stokes ..
Re Stokes [2008] WASC 269
The following passages are often cited in later cases.
You legal team is probably aware of this case and how to track later citations of it, even into 2018.
per MARTIN CJ (with whom the others agreed):
“32 An applicant who has been previously struck from the roll must bear a much heavier and distinctly different onus to that borne by an applicant seeking admission for the first time. In the case of an applicant for readmission, the applicant carries the onus of proving that there is no significant prospect of repetition of the conduct of the kind which resulted in the removal of his or her name from the roll – see Gregory v Queensland Law Society Inc [2001] QCA 499; [2002] 2 Qd R 583 at [18]. In this context it is worth repeating that the jurisdiction of the court in respect of the maintenance of the roll of practitioners is not a jurisdiction exercised for the purpose of punishing practitioners, but for the purpose of protecting the community (Clyne v The New South Wales Bar Association [1960] HCA 40; (1960) 104 CLR 186 at 201 – 202), which depends upon the provision of legal services by practitioners of appropriate character, honesty and integrity.
33 However, if the court can have the requisite confidence that there will be no significant risk of repetition of the misconduct which resulted in the removal of the practitioner’s name from the roll, there is a public interest in the restoration of the names of such persons to the roll. That public interest derives in part from the fact that such persons will be in a position to serve the community by providing legal services, but also from the encouragement of rehabilitation and redemption of those whose conduct has, in the past, prevented them from conducting their profession – see Kirby P in Kotowicz v Law Society of New South Wales, unreported; NSWCA; 7 August 1987.
34 The legal profession appears to be unusually vulnerable to mental illness. A number of reports have suggested that the rate of mental illness within the legal profession is rather higher than that within the community generally. Obviously, the community must have confidence in the capacity of those who are admitted to practise law. The authorities responsible for regulation of the profession, and the court, must be vigilant to ensure that the public is protected from those who lack that capacity for whatever reason, including mental illness. However, where the court can be satisfied by evidence that the incapacity, which resulted in appropriate steps being taken to protect the community, is no longer present, it will equally be in the interests of the community to take steps to enable the practitioner to resume the delivery of services.”
XY v The Board of Examiners [2005] VSC 250
As Dr Sharpe summarised:
“Similarly in XY, XY was a young solicitor who was admitted to practice after the court accepted her evidence that she was no longer suffering from a mental illness. XY had been sexually abused as a child and had gone on to heavily abuse alcohol and engage in other self-destructive behaviour. XY was later diagnosed as suffering from a „borderline personality disorder with impulsive disruptive behaviour and self-mutilation risk‟ and received medical treatment. Despite her mental illness XY managed to complete her law degree. At the time she sought to be admitted to practice XY was able to produce to the court medical evidence that she no longer suffered from a mental illness.”
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Part Three
As a brief(!) sample of later reported judgments that cite any of the above, see:
Re an Application by L for Admission as a Legal Practitioner [2015] ACTSCFC 1
See especially paragraphs 19 to 23.
On the importance of evidence for the Court to make its own decision, see Dixon v Legal Practice Board of Western Australia [2012] WASC 79.
A recent example which restated the principles (in WA): Pepe v Legal Practice Board of Western Australia [2016] WASC 54 (go to the judgment to see the citations in footnotes)
“Readmission – legal principles
12 The principles applicable to an application to be readmitted following having been struck off are well established.
13 The question of whether a practitioner should be readmitted is a matter to be determined by the court, which is not bound by the view of the Board reflected in the compliance certificate.[5]
14 Proceedings in respect of readmission of practitioners are appropriately conducted in public.[6]
15 The approach to be taken on application for readmission was outlined in Re Stokes, as follows:[7]
An applicant who has been previously struck from the roll must bear a much heavier and distinctly different onus to that borne by an applicant seeking admission for the first time. In the case of an applicant for readmission, the applicant carries the onus of proving that there is no significant prospect of repetition of the conduct of the kind which resulted in the removal of his or her name from the roll – see Gregory v Queensland Law Society Inc [2001] QCA 499; [2002] 2 Qd R 583 at [18]. In this context it is worth repeating that the jurisdiction of the court in respect of the maintenance of the roll of practitioners is not a jurisdiction exercised for the purpose of punishing practitioners, but for the purpose of protecting the community (Clyne v The New South Wales Bar Association [1960] HCA 40; (1960) 104 CLR 186 at 201 202), which depends upon the provision of legal services by practitioners of appropriate character, honesty and integrity.
However, if the court can have the requisite confidence that there will be no significant risk of repetition of the misconduct which resulted in the removal of the practitioner’s name from the roll, there is a public interest in the restoration of the names of such persons to the roll. That public interest derives in part from the fact that such persons will be in a position to serve the community by providing legal services, but also from the encouragement of rehabilitation and redemption of those whose conduct has, in the past, prevented them from conducting their profession – see Kirby P in Kotowicz v Law Society of New South Wales, unreported; NSWCA; 7 August 1987.
The legal profession appears to be unusually vulnerable to mental illness. A number of reports have suggested that the rate of mental illness within the legal profession is rather higher than that within the community generally. Obviously, the community must have confidence in the capacity of those who are admitted to practise law. The authorities responsible for regulation of the profession, and the court, must be vigilant to ensure that the public is protected from those who lack that capacity for whatever reason, including mental illness. However, where the court can be satisfied by evidence that the incapacity, which resulted in appropriate steps being taken to protect the community, is no longer present, it will equally be in the interests of the community to take steps to enable the practitioner to resume the delivery of services.
16 The power to readmit should be exercised with caution and only upon solid and substantial grounds.[8]
17 Among the relevant considerations is the need to maintain appropriate standards and preserve the reputation and standing of the legal profession, and whether that would be eroded if the applicant were readmitted.[9]
18 The question for the court is whether the applicant is a fit and proper person to be readmitted to the legal profession. That question is to be determined without regard to whether any conditions should or might be imposed upon a practice certificate issued to the applicant.[10]”
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Thank you! I am self-representing and this is much appreciated!
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Thank you. My empathy, sympathy, and compassion are cognitive: mechanistic, not mentalistic. I do not “feel” other people’s pain because I have no right to do so— it is none of my business.I rescue people in trouble because it is my civil and social duty: hitch hikers; cars with flat tires; homeless people begging— I help them because I am supposed to, not because I want to.
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Those that expose their ability’s to the world and comes off as different, is nothing more than God showing us that we don’t set the standards ( he does ) I have met few people in my life ( no matter how quirky ) that didn’t show ability’s that other ,more educated people lacked. What I found in most cases was the person showing none of these abilities were lazy or had other disorders to express theirselves well, would be proud to have you helping our family
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Do people with autistic disorders know that they aren’t on the same plane with the masses but taking the same life trip just the same . Some I feel see to lean on it for attention. In order for the world to understand them ,we must first understand Autistic people’s plight better than the generation before us.
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