The dyslexic surgeon

Dyslexia is a common learning difficulty, affecting ten per cent of the population worldwide. The British Dyslexia Association defines dyslexia as a learning difference that can have a significant impact on education, in the workplace and daily life that mainly affects reading and writing skills. It is primarily a neurological variance that affects information processing within the brain.¹ In 2009, The Rose report described dyslexia as a learning difficulty that affects skills involved in accurate and fluent word-reading and spelling. Dyslexia can have a vast range of effects on an individual and occurs more as a continuum than in discrete categories. Importantly, it may affect any person irrespective of their intellectual ability.

Classically, dyslexia exhibits features such as difficulties with phonological awareness, verbal memory and verbal processing speed. As a condition that exists on a spectrum, each individual’s experience of dyslexia varies.²

Currently there are limited reports on the incidence of dyslexia and other specific learning difficulties among medical students or working doctors. In 2009, the British Medical Association suggested that 1.7% of medical students could have a learning difficulty. A report by Brighton and Sussex Medical School in 2013 suggested that 10% of their students may have had identified learning difficulties.³

The day-to-day working as a surgical trainee requires the use of many skills and dyslexia can have an effect on each of them. Some particular challenges include:

People with dyslexia have a remarkable ability to develop mechanisms to compensate and cope with these difficulties. However, it is often reported that challenges such as these can lead to feelings of isolation, inadequacy and poor self-esteem. Furthermore, dyslexia may not present in isolation and it often coexists with other learning difficulties such as dyspraxia and dyscalculia.³

Dyslexia translates literally as a ‘difficulty with words’.⁴ Examinations pose a significant challenge to dyslexic medical students and doctors, especially if they involve multiple choice or extended matching questions. All junior surgical trainees must complete the MRCS qualification by the end of ST2/CT2 in order to progress into ST3 registrar training.⁵ The Intercollegiate MRCS Part A examination takes the format of two multiple choice papers and this milestone can be a real worry for the surgical trainee with dyslexia.⁶

In 2008, a second year medical student challenged the use of the MCQ exams to monitor an individual’s progress, claiming that they were putting individuals with dyslexia, such as herself, at a disadvantage compared to her peers. This drew much media attention. Dr John Rack, head of psychology at Dyslexia Action, commented to the BBC that people with dyslexia can struggle with multiple choice examinations because of having to process large amounts of information at any one time, which requires the use of a person’s working memory. When there are multiple options, it is extremely challenging for dyslexic people to keep track of information in this way. People with dyslexia also usually read more slowly, which adds time pressures to an already very stressful situation for them.⁷ Oxford University neuroscientist Professor John Stein, a prominent expert in dyslexia, also commented on the case, saying that people with dyslexia struggle with multiple choice exams due to their poor eye coordination.⁸

Owing to the fact multiple choice examination papers can pose an additional challenge to dyslexic people, for surgical trainees this can add additional stress, pressure and anxiety. They may find it harder to pass postgraduate exams or take more attempts than the average trainee to be successful. It has been reported that medical students with dyslexia take longer to adapt to medical school and can underperform (academically) early in the course. With appropriate support, they can progress to perform on par with their peers as they progress with their studies.³ Perhaps the same could be inferred for surgical trainees in the early years of their training with regards to MRCS examinations, for example.

In the UK, dyslexia is recognised under the Equality Act as a specific learning difficulty, and therefore merits educational adjustments.⁹ Such adjustments include but are not limited to:

Additional time for written examinations has been accepted as a reasonable adjustment for a number of learning difficulties, including dyslexia. It is worth noting, however, that in postgraduate exams lasting many hours the resulting prolonged period of intense mental working can result in question fatigue. In addition, this action can have the effect of ‘singling out the individual’ to other examination candidates. Many may not have disclosed their diagnosis to their peers. Aside from the daily challenges that can occur from being dyslexic or additional pressures when taking exams, dyslexic doctors can experience feelings of isolation.

In 2017, Shaw et al sought to answer the question, ‘What are the lived experiences of medical students and junior doctors with dyslexia?’ It was disappointing that the study revealed that there is a continued fear of being identified as dyslexic.¹⁰ Interviews with junior doctors showed that there was a stigma attached to the ‘label’ of dyslexia. They were reticent to disclose their diagnosis as they were fearful that they would be viewed as struggling and unable to cope. There remained a lot of fear and anxiety around passing exams which directed career choices.

The interviews conducted by Charles et al concluded that there was a world of stigma, stonewalling, bullying and a reluctance to disclose.¹⁰ Some of the comments recorded from interviewees of their experiences from other doctors’ reactions to their diagnosis included:

‘Most people (doctors) don’t see it as a real… They don’t see it as real. They just see it as made up.’

‘I remember on firms and things… I was told “people aren’t dyslexic” or something like that. Some people would be like “oh, yeah, but is it a real thing?”’

‘I don’t think they kind of understand the psychological impact on people.’

Respondents also commented on the emotional impact of having a diagnosis of dyslexia:

‘I constantly… felt… self-conscious about it.’

‘I felt like my brain wasn’t as good as other people’s brains.’

Although dyslexia does not have an effect on a person’s intelligence, there is still a feeling among dyslexic doctors that they can be viewed as less able or less intelligent compared to their peers.¹⁰ Dyslexic doctors will generally have to work harder in being organised for everyday activities and preparing for exams. Colleagues may not always recognise that fact or take it into account when considering the physical, mental and emotional impact it can have on a person.

On the other hand, having dyslexia can create challenges for surgical trainees but it can also have advantages. Surgical training demands a lot of the skill sets that neurodiverse individuals excel in, such as:

Additionally, people with dyslexia learn more from experiences rather than abstractions and because of the educational challenges dyslexia can pose, these experiences can indeed make dyslexic trainees more natural and involved teachers. Nonetheless, from the limited studies into how dyslexia can affect medical students and junior doctors, it is clear that there is a need for better awareness of dyslexia in the profession and more robust lines of support for dyslexic doctors. Support appears to be adequate during the undergraduate years, but many have commented that there was a distinct lack thereafter.

In terms of how we can improve the support and general working environment for surgical trainees with dyslexia, trainers and educators need to be trained to understand how dyslexia presents. Dyslexic trainees need to feel comfortable and able to disclose their diagnosis to those with whom they work with on a day-to-day basis. Work colleagues should be educated about dyslexia and recognise how reasonable adjustments can be made for dyslexic colleagues.

Ideally, a dedicated team should be available within the postgraduate training organisation who can provide support to neurodivergent trainees, helping with implementing reasonable adjustments.¹² Ensuring training platforms such as e-portfolios are accessible and user friendly for dyslexic trainees.¹¹

For current surgical trainees, there are support services available via the individual deaneries. In Scotland, there is also the Scottish Deanery Performance Support Unit.¹³ The Intercollegiate Committee for Basic Surgical Examinations also has a reasonable adjustments policy which those diagnosed with dyslexia can engage with.¹⁴ There is however a pressing need for further research into how dyslexia affects the working life of doctors. There continues to be a lack of understanding within the medical profession of what dyslexia actually is. Continuing stonewalling, stigmatisation and discrimination detracts from medicine being an equitable and supportive profession. Doctors with dyslexia are able practitioners who may have skills others do not possess owing to the fact they have had to cope with being dyslexic and compensate for it.¹⁰

A dyslexic surgical trainee is a valuable member of the team. We should recognise their skills and qualities, which can contribute to them being able surgeons, and support them in the areas which they may find more challenging. Most importantly, we as a profession should ensure that they do not feel isolated, stigmatised or discriminated against. We should ensure that our colleagues are educated about dyslexia. Surgery is a dynamic, evolving specialty and we should embrace our neurodiverse colleagues and what they can bring to the table.