I. Introduction
Intersectionality — the theory that the individual marginalizations of distinct social identities compound to generate overlapping and interdependent systems of discrimination or disadvantage — has come to dominate recent discussion of systemic injustice in healthcare and medical education.Reference Crenshaw1 In conjunction with recognition of the impact of physician identity on health disparities, this wave of intersectional consciousness has spurred new initiatives to increase diversity within the medical educational pipeline.2 While such initiatives have consistently emphasized the need for greater diversity in terms of race, ethnicity, gender, and sexuality, few training programs have even begun to consider how people with disabilities have been systematically excluded from careers in medicine.Reference Waliany3 One potential explanation for this oversight is the presumption that, unlike other forms of identity, disability — especially mental disability — is necessarily disqualifying from the practice of medicine.4 Medical trainees and physicians who identify as disabled are indeed a small minority.Reference Meeks and Jain5 However, symptoms of mental disability pervade medicine, affecting physicians and physicians-to-be across clinical specialties and at all stages of their training and career.Reference Mehta and Edwards6
The apparent paradox of mental disability among physicians as simultaneously rare and ubiquitous is a product of a profound and deeply ingrained stigma within medicine toward disability in general and mental disability in particular.Reference Wallace7 In spite of legislative efforts to ensure equal access for persons with disabilities, healthcare and medical educational systems continue to impose steep barriers on aspiring physicians with mental disabilities and violate their legally guaranteed rights in myriad ways.Reference Haque, Stein and Marvit8 From medical school admissions through licensure, aspiring physicians are deterred from disclosing mental disabilities by fear of jeopardizing their careers. In such a manner, the stigmatization of mental disability not only forces countless individuals to “suffer in silence” without necessary accommodation or treatment but also precludes empirical study of the impact of appropriately accommodated physician mental disability on patient care.Reference Ouellette9 Moreover, the failures of legislation to secure meaningful access for persons with mental disabilities to medical education and employment underscores both the inadequacy of legislative solutions and the need for social and cultural changes within the medical profession.Reference Stein10
Here we consider two underexplored aspects of prejudice toward mental disability in medicine. First, we articulate the public health implications of such stigma for physicians and patients. Second, we draw parallels to other marginalized identities in order to speculate about the potential benefits of greater inclusion of physicians with disabilities. Collectively, we assert that the stigmatization and the categorical exclusion of persons with mental disabilities from the medical profession ought to be approached as an issue of intersectional social justice, argue that that the exclusion of such physicians is antithetical to the professional goals of medicine, and propose paths toward more effective and just medical education and healthcare systems.
Here we consider two underexplored aspects of prejudice toward mental disability in medicine. First, we articulate the public health implications of such stigma for physicians and patients. Second, we draw parallels to other marginalized identities in order to speculate about the potential benefits of greater inclusion of physicians with disabilities. Collectively, we assert that the stigmatization and the categorical exclusion of persons with mental disabilities from the medical profession ought to be approached as an issue of intersectional social justice, argue that that the exclusion of such physicians is antithetical to the professional goals of medicine, and propose paths toward more effective and just medical education and healthcare systems.
II. Public Health Implications for Physicians and Medical Trainees
The definition of disability is a subject of heated scholarly debate.Reference Francis and Silvers11 For the purposes of this paper, we deploy the definition put forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for mental disorder, defining a mental disability as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.”12 Such syndromes include psychiatric illnesses, neurodevelopmental disorders, and learning disabilities. By this definition, mental disabilities are extremely common within the U.S. population and represent one of the most prevalent forms of disability: an estimated 26.2% of Americans will meet the criteria for a DSM diagnosis in any given year with 46.4% meeting those criteria at some point in their lives.Reference Kessler13
Though they report disability at a rate far lower than that of the population writ large, the actual prevalence of mental disability among medical trainees and practicing clinicians is unknown and mounting evidence suggests that it is on par with if not surpassing that of the general population.Reference DeLisa and Thomas14 For example, approximately a third of all physicians self-report symptoms of depression and/or anxiety with even higher rates among medical students and residents.Reference Mata15 The discrepancy between reported and actual rates of mental disability among physicians is a product of physician’s reluctance to disclose their conditions which is, in turn, a product of the stigma surrounding such disabilities. Given that disclosure of mental disabilities is prerequisite to access to the treatment and accommodations one might need to manage them, the reluctance of physicians and medical trainees to disclose mental disabilities warrants consideration of this group as a uniquely vulnerable patient population. In this section, we, thus, explore the consequences of the stigma toward mental disability within medicine for the health of physicians and trainees themselves.
Numerous studies affirm that physicians and physicians-to-be indeed face distinct barriers to treatment and accommodations, resulting in underutilization of these services. One study found that only half of depressed medical interns sought treatment.Reference Guille16 Another found that while 25-30% of medical students met the diagnostic criteria for depression, only 0.3% sought accommodation.Reference Meeks17 These studies were conducted concomitantly with a surge of wellness initiatives on medical campuses aimed at reducing the mental health stigma.Reference Schutt18 Trainees’ continued reluctance to disclose mental disabilities despite attempts to create a ostensibly safer environments for them to do so illustrates just how deeply entrenched prejudice against mental disability is within the culture of medicine. We posit that the medical profession’s ability to reckon with this prejudice and adopt principles in line with disability justice may be uniquely fraught because of the central role of physicians in the construction of disability.19 In their diagnosis of “disease,” physicians designate select variants of human anatomy, physiology, and/or behavior as deficits in need of correction.Reference Barnes and Barnes20 By conflating difference with detriment and conferring value to individuals on the basis of their conformity to ideals of species-typical form and function, medicine plays a central role in the promulgation of ableism.Reference Haque, Lenfest and Peteet21
We further speculate that the performative ideals of the medical profession render physicians particularly prone to bias against persons with mental disabilities. In the notoriously competitive environment of medicine, physicians with mental disabilities may receive the message that their conditions, in contrast to more tangible forms of disability such as physical handicaps, are merely excuses for character flaws or personal failings. One of the most pernicious aspects of the stigma against mental disability is that physicians may internalize such messages, believing that they do, in fact, just need to work harder to compensate for their shortcomings and, thereby, enacting stigma against themselves.Reference Corrigan and Rao22 Perfectionistic, having internalized ideals of self-reliance, and predisposed to “imposter syndrome,” many physicians eschew self-care to more fully devote themselves to work in romanticized acts of self-sacrifice.Reference Dyrbye, Thomas and Shanafelt23 Rather than address their struggles, physicians often thus conceal their conditions, attempting to succeed while simultaneously denying themselves the accommodations they require to do so.24
Unable to solicit support, physicians and medical trainees may feel left to their own devices to cope in an unsustainable model which may account for the documented worsening of student mental health upon matriculation into medical school and the ubiquity of burnout among medical practitioners.25 Though categorized as an “occupational phenomenon” rather than “medical condition” by the International Classification of Diseases (ICD), burnout manifests from the same chronic stressors known to contribute to psychiatric illnesses and is often seen as a driving force behind the high levels of suicidal ideation and suicide among physicians.26 Over their lifetimes, approximately 17% of physicians report experiencing suicidal ideation, compared to 9% of the general population.Reference Dong27 Physicians also die by suicide at about twice the rate of the general population.28 The pursuit of medicine requires so many arduous years of dedication and sacrifice that many burnt-out physicians cannot imagine lives beyond the careers making them miserable.
II. Public Health Implications for Patients
Stigma toward mental disability within medicine harms not only practitioners but also their patients. In this second section, we first describe how such stigma harms patients broadly before addressing its potential for distinct harms toward certain patient populations. The attrition of doctors due to burnout has resulted in chronic provider shortages and discontinuity of care.Reference Reith29 Physicians’ stigmatization of mental disabilities further compromises the quality of care provided.Reference Pellegrini30 The physician-patient relationship crucially mediates the efficacy of therapeutic interventions, and mistrust between patients and clinicians contributes to lower quality of care.Reference Ha and Longnecker31 Physicians unable to acknowledge and address their own mental suffering may struggle to empathize with their patients’ experiences and may even be more likely to dismiss their patients’ suffering or overlook relevant symptomology. Patients who do not receive empathetic treatment may, in turn, be less inclined to trust their clinicians and be forthcoming about their symptoms. Moreover, while there is no evidence that a physician’s diagnosis itself confers greater risk of harm to patients, physicians who are experiencing significant distress are more prone to making mistakes and inadvertently harming their patients.Reference Dewa32
As key interlocutors in public discourse on health and wellbeing, physicians’ personal health habits may impact how effectively they counsel patients in adopting similar practices.Reference Oberg and Frank33 Consequently, when doctors neglect their mental health and eschew treatment, they may decrease the likelihood that their patients will pursue similar therapeutic interventions. By contrast, patients may be more likely to adopt health habits that they believe their doctors personally implement. All persons, even those without chronic mental disabilities, may at one time or another face mental health challenges due to difficult life circumstances and benefit from mental health services. By refusing to acknowledge and address their own mental health challenges, physicians thus not only perpetuate their own suffering but also societal stigma toward mental health treatment and, in turn, the suffering of their patients.
While the stigma toward mental disability is harmful to patients writ large, there is one population, however, that is likely to be unduly harmed by the continued stigmatization of physicians with mental disabilities: patients with disabilities. As previously described, ableist values are often enshrined within physicians’ core sense of professional identity. Honing their trade in a culture that romanticizes masochistic struggle in the name of success, many physicians come to conflate human worth with the ability to produce and achieve. By staking their own moral value in a specific set of vaunted professional abilities, physicians may struggle to uphold the full humanity of patients whom they perceive to lack those capacities and skills. Even implicit bias may affect physicians’ treatment of their patients and, in turn, quality of care and healthcare outcomes. One study found that while most providers denied holding ableist attitudes, the overwhelming majority exhibited implicit preference toward nondisabled persons.Reference VanPuymbrouck, Friedman and Feldner34 Such preferences undoubtedly contribute to the substantial health and healthcare disparities experienced by persons with disabilities.Reference Iezzoni35
III. The Need for Greater Representation of Mental Disability ithin the Medical Profession
With respect to race and gender, research suggests that increased representation among physicians may help reduce health disparities for marginalized populations.Reference Alsan, Garrick and Graziani36 Given the present barriers to entry and disclosure facing aspiring physicians with mental disabilities, however, it is challenging if not impossible to empirically evaluate how increased numbers of such physicians affect the healthcare outcomes for mentally disabled patients. Nonetheless, we speculate by analogy that greater representation of physicians with mental disabilities offers considerable promise as an intervention to both better serve mentally disabled patients and to abrogate many of the public health challenges described in the previous sections. We further argue that there is a need for more physicians with mental disabilities because we believe that persons with mental disabilities represent a source of tremendous untapped potential as physicians.
We contend that physicians with mental disabilities might bring much needed perspective into the classroom and clinic, especially their insight into the lived experience of disabled patients.Reference Haque and Waytz37 Where persons with disabilities are viewed by physicians solely through a clinical gaze, they become “othered,” endowed with lesser humanity and subject to the numerous consequences of clinical dehumanization.Reference Tolchin and Stein38 Conversely, the perceived distance between nondisabled physicians and persons with disabilities might be lessened by the recognition of those persons not solely as patients but also as peers. Moreover, by listening to such peers testify to their own experiences, nondisabled physicians might develop greater empathy toward their disabled patients.
In addition to teaching others, we propose that physicians with mental disabilities might themselves be exceptionally empathic clinicians. Even for disabled physicians and patients with discordant diagnoses, the mere fact of having personally navigated medical care with a disability can heighten physicians’ capacity for empathic treatment. Moreover, emerging evidence of the “double empathy problem,” which posits that the communication breakdowns between autistic and non-autistic people are caused by mutual misunderstandings, suggests that neurodivergent patients may feel more comfortable with and better understood by neurodivergent physicians who share their distinct style of communication and experiences. Thus physicians with mental disabilities may be able to relate to and serve specialized patient populations in ways that neurotypical physicians cannot.Reference DeThorne39
Finally, we posit that the greater inclusion of mentally disabled physicians would infuse new creative talents into the field of medicine. Simply by virtue of having a disability, a person is forced to become resilient and adept at problem-solving in the face of obstacles; such creativity could prove key to breaking stalemates in the development of novel therapies, and open up new conceptions of human flourishing not limited by notions of species-typical and mechanistic functioning.40 While we wish to resist fetishization, we submit that specific subsets of mental disabilities might even prove advantageous in specialized medical fields.Reference Moore, Kinnear and Freeman41 For example, individuals with neurodevelopmental conditions such as dyslexia and autism spectrum disorders demonstrate exceptional pattern recognition and might therefore excel in highly visual specialties such as radiology.42
IV. Ways to Better Norms
People with mental disabilities are already active practitioners of medicine. They have thus already demonstrated the non-mutual exclusivity of mental disability with success in medicine. These physicians, however, have done so despite enormous, needless, and preventable barriers and suffering. Untold numbers of additional individuals with mental disabilities might also have become capable doctors had doing so not required such ordeals. In this final section, we propose means to leverage public health and disability justice frameworks to eliminate barriers to entry and retention within the medical field for physicians and trainees with mental disabilities. Rather than focus on specific administrative, logistical, and policy proposals, which have been explored elsewhere, we first describe the conceptual and cultural shifts necessary for medicine to truly integrate physicians with mental disabilities and then broadly outline the types of policy changes which might be implemented toward that goal.43
To dismantle its deeply entrenched stigma toward mental disability, medicine must first acknowledge the ableist features of its academy and its present conception of “wellness.” As it stands, medicine frequently frames wellness in narrow terms which constitutionally exclude persons with mental disabilities. Even as medical education increasingly employs competency based evaluations to reduce bias through ostensibly more objective metrics, “wellness” continues to be included in various forms as a “core competency.” The Common Program Requirements for Residency put forth by the Accreditation Council for Graduate Medical Education, for example, declare that residents and faculty are personally responsible for the “recognition of impairment, including from illness, fatigue, and substance use, in themselves, their peers, and other members of the health care team” and goes on to state that:
Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician and require proactive attention to life inside and outside of medicine. Well-being requires that physicians retain the joy in medicine while managing their own real-life stresses. Self-care and responsibility to support other members of the health care team are important components of professionalism; they are also skills that must be modeled, learned, and nurtured in the context of other aspects of residency training.44
When “self-care” and management of “real-life stresses” are parameters on which an individual’s competency is evaluated, wellness necessarily becomes performative and its achievement limited by an individual’s ability to effectively perform a specific version of wellness. In an interview for the Docs with Disabilities podcast, University of Toronto psychiatry resident and researcher Dr. Erene Stergiopoulos describes how the typical framing of wellness “as a means to achieve … ideal medical students’ status” embodies contradictions which create specific barriers for students with disabilities, including mental disabilities. She explains that this framing:
becomes this way of excluding people because it says, if you can’t perform these very conspicuous self-care activities, like drinking a green smoothie or doing yoga at lunch, you’re not actually performing wellness properly. So you think about students with disabilities who might need to spend a lot of their self-care time doing very different types of activities. What does that say to them? Are they appropriate for medicine if they can’t perform those roles?… Students were … pulled in completely opposite directions where on one hand they’re supposed to be extremely high performing and not need help. And then on the other hand, as someone with a disability or someone who is a patient, they need to completely self-manage and spend all of their time on self-management, which kind of precludes the ability to do well in school.45
If wellness continues to be defined in terms of a student’s ability to perform, and “psychological, emotional, and physical well-being” continue to be requisite to study and practice medicine, then students who display or admit to struggles with their well-being risk exclusion from the medical profession.
Thus, the deconstruction of prejudice and stigma toward mental disability within medicine must begin with a fundamental reconception of “wellness.” Rather than weaponizing wellness as yet another criterion on which students are comparatively judged, wellness should be reframed in individual terms, taking into consideration a student’s unique challenges, abilities, values and goals. Rather than delineating specific self-care activities, schools should take steps to promote and normalize a broader notion of self-care which might look quite different between individuals. Furthermore, schools should also consider eliminating wellness as a competency among students, and rather, see it as a competency among schools, where different institutional features will produce variations in student wellness outcomes. Although trainees in schools are not identical to patients in hospitals, there are nonetheless important similarities in being vulnerable, lacking knowledge, and being at higher than average risk of morbidity and mortality; therefore, just as hospitals are evaluated on the mortality of their patients, medical schools should be evaluated on the wellness of their trainees. Vulnerability and interdependence are our common conditions as humans, and not imperturbable independence.Reference Snead46 Therefore, wellness is an obligation medical institutions have towards their trainees, not one trainees primarily have towards medical institutions.
In its quest to become more inclusive, medical education must move beyond its singular and overwhelming focus on race, gender, and sexuality issues, and would do well to heed the disability rights mantra ‘nothing about us without us’ by also incorporating disability rights and advocacy perspectives into its curriculum. In a manner akin to their approach to issues of race, gender, and sexuality, schools might allow space for students to speak from their own experiences while also raising awareness of the burdens that students with mental disabilities may carry as a result of tokenism. All medical school faculty should undergo specific sensitivity training for teaching and overseeing students with disabilities. Persons with disabilities should also be included as peers and participants in training students to address their needs.
Alongside elimination of barriers to entry and retention for other marginalized populations within medicine, we assert that these reforms to promote greater inclusion of physicians with mental disabilities are not only expedient but long overdue measures to diversify the physician workforce. These measures are not charity, but rather a crucial stride toward resolving pressing inequities in our current healthcare infrastructure.
In addition to striving to be more superficially inclusive, the field of medicine must also operationalize accessibility for individuals with mental disabilities. Training programs should create a ‘road map’ for these students, consisting of clear, welcoming messaging to applicants and trainees at various stages regarding disability policies and confidentiality practice, including articulation of the structures in place to support students and to protect them from discrimination in disclosing their disability statuses and applying for accommodations.47 This map should clearly state that mere admission of struggle to administrators will not automatically result in a forced leave of absence while simultaneously reframing the notion of a leave of absence as a sometimes necessary break rather than an irreparable failure. Moreover, programs should establish peer mentoring or other support networks for students with mental disabilities to foster a sense of community and demystify their unique “hidden curriculum.”
Alongside elimination of barriers to entry and retention for other marginalized populations within medicine, we assert that these reforms to promote greater inclusion of physicians with mental disabilities are not only expedient but long overdue measures to diversify the physician workforce. These measures are not charity, but rather a crucial stride toward resolving pressing inequities in our current healthcare infrastructure.
