Being somewhat venerable (a Fellow of the College of Family Physicians of Canada with a practice career spanning 23 years and counting), working within academic medicine, and having a number of illnesses that have necessitated participation in various recovery regimens in different provinces for more than 20 years, I have developed opinions about the thorny issue of physician self-disclosure of illness within professional contexts.
I will summarize the obvious: ableism is rampant in the profession, so strong a form of oppression that it operates in a largely tacit fashion. I have written about the philosophical reasons why in different forums before,1-4 so I will not recapitulate that argument here. Instead, I will point out that the problem starts in society itself first as stigma, then becomes operative during the medical school admissions process, which is neither accessible nor explicitly welcoming to disabled applicants (S. Gertsman, Y. Dini, D. Wilton, and S. Neilson, “Barriers to Canadian medical school admissions for students with disabilities,” unpublished data, May 2023).5 The problem builds on this pre-existing base in medical school, in which students are socialized to never disclose illness or impairment based on the aforementioned medical philosophy as it manifests in the hidden curriculum, in role models and mentors, in extreme efficiency expectations, and in fears of not successfully matching to a preferred career path.5-7
As a student adviser, I am especially aware of this last worry, and it is entirely reasonable: students face greater consequences in terms of mandated leaves, often perceived rightly as a punishment and negatively impacting their career trajectory in the eyes of residency program directors, whereas practising physicians tend to be approached with accommodation and rehabilitation in mind. That said, concerns introduced in medical school only compound as the physician progresses in training and then practises independent medicine, where responsibilities increase and obligations to patients and colleagues intensify. For their part, practising physicians face a disadvantage when applying for annual medical licensure. In North America, many colleges employ ableist practices that expect disclosure of substantial past physical and mental illness rather than current illness that affects functioning.8,9 This, despite recommendations of many authorities to the contrary10,11 and more progressive examples from other countries that possess some evidence of increased self-referral for seeking help.12,13
Fears of discrimination
Unfortunately, these facts are not gleaned merely from journal articles. They are corroborated by my lived experience. In my Caduceus support group for health professionals, for example, collective wisdom strongly militates against self-disclosure for any reason other than being directly asked by a regulator for the purposes of licensure. Fear of the regulator is real and righteous, for we are aware of many instances of an overly punitive stance taken against group members. Moreover, these licensure questionnaires often discriminate between physical and mental illnesses, distinguishing the current impact of physical illness but not of mental illness, suggesting that physicians with mental illness shall be eternally suspect; nor is there adequate explanation of how to respond to items on the questionnaire. Responding the wrong way to the binary answer expectation (yes or no) regarding health status can trigger a review process and delay licensure unnecessarily.
One would think that, in the era of equity, diversity, and inclusion, ableism would be identified as a form of oppression to be eradicated in medicine on equal footing with other forms of oppression. However, several authors5,14 have pointed out that in contrast to anti-homophobia, anti-transphobia, and antiracism initiatives, accommodation and destigmatization initiatives have not taken commensurate root,* although here I add a neoliberal rationale to the mix: having queer and racialized physicians is an obvious benefit to care in that, through identification, patients can feel better heard and understood, and there is some evidence that such is the case.15,16 In Canada’s socialized health care system, specific patient populations can receive these improved outcomes, resulting in less economic expenditure for unaddressed or poorly managed health problems. Self-identifying physicians who have experienced previous illness also fit into this logic17 concerning disabled patients only if there is no functional impact upon normative expectations of superdoctorish current practice. Such is often not the reality for disabled physicians, be they either “physically” or “mentally” disabled—I make no distinction, personally, treating both as the same interlinked non-Cartesian category—who often cannot see patients as quickly, nor with the same expansive work hours. Moreover, disabled patients require more time for care than those without a chronic condition, reducing system efficiency. In short, ableism, normative biomedical philosophy, and neoliberalism create a uniquely impactful perfect storm dissuading disclosure of personal illness and disability in all professional contexts (save the case of patients, where the niceties around disclosure are quite different).18-22
Beyond policies and processes
Policy elements that could improve the plight of ill† and disabled physicians have already been articulated23-25: solicit medical school applications from ill and disabled students explicitly via public outreach. Make admission policies accessible. Have disability-conscious faculty mentors available to, and confidential accommodation administrators embedded within, undergraduate and graduate faculties. Change medical licensure processes. All these policy and personnel changes would assist future and current physicians at many stages with diverse conditions,‡ but the ultimate overall effect is intended to instigate cultural change, from which further profession-wide transformation can result.
Yet there is a cultural front that policy change cannot reach, which brings me to the unique opinion I bear based on my own range of life experiences. Since Call Me Doctor,26 my first book-length publication, was released in 2006, I have written about suicidality, bipolar disorder, addiction, trauma, abuse, and autism as they concern my personal practice of medicine in literary venues and forums.27-31 I will also cover ableism within the medical community in an upcoming book. In 2023 I published Saving,32 a memoir that recounts episodic periods of psychosis over the course of my medical career, occurring at times of great stress. I mention these individual items as a call to other physicians to normalize vulnerability on the cultural front both within and without medicine. It is not enough to practise medicine with disability consciousness. We must also tell our stories to one another such that representations circulate in medical culture—lively ones that display lived experience in time and space, attesting truthfully to difficulty, joy, exclusion, structural inequity, and simple survival. In this way, individuals who are suffering can feel comfortable seeking help, and working alongside self-identifying individuals can be normalized. We will have our stories such that we can know ourselves to one another.
Tales outside the ableist 3-part play
Furthermore, this work needs to be conducted as publicly as possible, where it is accessible for all to read. It is not enough to speak at carefully choreographed conferences that largely adhere to the familiar 3-part play (“I got sick; I came to the ‘Jesus’ known as the Physician Health Program; I got better and returned to full-time practice!”). Summary might be usefully dramatic to an audience in the moment, but it is simply not as chronic as the reading experience, not as enduring. The message is digestible and quick, like medicine’s preferred patient encounters.
As a physician who has lived “out” as mad and an addict for more than 18 years and as autistic for more than 3 years, I have long noticed the vanishingly small number of Canadian physician–authored texts concerning these identities that do not adhere to the ableist 3-part play.§ Our stories need to include those practitioners among us who remain symptomatic or affected and yet without impairment. We need complex and aesthetically beautiful tales of negotiation with health conditions that endure in all genres that exist beyond summary, that play in art. We need to do so for us, and we need to do it for our disabled patients, too, to help them trust us. For, why should they trust us if we hate what we are, that we are like them?
Notes
Suggested reading
Horton J. We are all perfectly fine: a memoir of love, medicine and healing. Toronto, ON: HarperCollins; 2021.
O’Shea A, Latham JR, McNair R, Despott N, Rose M, Mountford R, et al. Experiences of LGBTIQA+ people with disability in healthcare and community services: towards embracing multiple identities. Int J Environ Res Public Health 2020;17(21):8080.
Footnotes
↵* Oppression coordinates according to intersectionality, and multiple marginalizations stack.
↵† In my disability community, we use the word sick as a political decision to push back against stigma; however, because this is a medical audience, I have chosen to use the more familiar term ill.
↵‡ I dislike the term conditions, but for want of a better substitute, I have used it.
↵§ Physicians in other countries have largely performed this work, such as Drs Petre Jones and Adam Kay in the United Kingdom and Dr Mark Vonnegut in the United States. Canadian precedents are harder to come by but are by no means unprecedented.
Competing interests
None declared
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