Understanding attention deficit/hyperactivity disorder in physicians: workplace implications and management strategies
Maryna Mammoliti, MD, Christopher Richards-Bentley, MD, Adam Ly, MScOT, and Mary Nguyen, MD
Physicians with attention deficit/hyperactivity disorder (ADHD) may have unrecognized workplace difficulties because of inattention and impulsivity. If these behaviours interfere with patient care or organizational functioning, leaders may erroneously attribute the physician’s actions to unprofessionalism. As such, corrective efforts with punitive measures may be ineffective. ADHD is a neurodevelopmental disorder that responds to evidence-based treatments, including medications, accommodations, and supports. Physician leaders who understand the unique presentations of ADHD in physicians may better identify when this condition may be contributing to workplace behaviour. Furthermore, physician leaders may have a professional or legal duty to accommodate or support physicians with underlying medical and/or psychiatric conditions, such as ADHD. Using our own clinical experience, we provide a general overview of ADHD in physicians and guide physician leaders on how to help physicians who may be struggling with ADHD in the workplace. We hope that our clinical experience and observations of this hidden problem will spur discussion, awareness, and action for further research and support.
KEYWORDS: physician health, physicians with ADHD, workplace health, mental health management strategies, performance
CITATION: Mammoliti M, Richards-Bentley C, Ly A, Nguyen M. Understanding attention deficit/hyperactivity disorder in physicians: workplace implications and management strategies. Can J Physician Leadersh 2021;7(4):160-165 https//doi.org/10.37964/cr24742
Do you know a physician colleague who is always late to patient appointments or meetings? Do they submit their billings months late? Are they constantly behind in charting? Do they seem overwhelmed all the time? Have colleagues or patients complained that they were “impatient,” “rude,” or “interrupting”? Do they excel and focus on one area of practice very well, but other responsibilities are forgotten? Perhaps they are not prepared for the reality of medical practice, lack practice management or coping skills, or experience chronic stress. Perhaps they were always like that. Perhaps you ignore it, provide some tips or suggestions, or think they are just not up for the job. Top
From our clinical experience and practice as psychiatrists and an occupational therapist, we have observed an increasing proportion of physicians who struggle with some of the above difficulties. These physicians recognize that these problems are having a significant functional impact on their personal and professional lives and, consequently, seek professional help. They may have completed coursework, remediation programs, or coaching with little resolution. Through their family physicians, the provincial physician health program, or social media interest groups, these physicians enter our practice, where their life history and presenting problems fit the criteria for a diagnosis of attention deficit/hyperactivity disorder (ADHD). Once given a diagnosis, they are comforted by the fact that their professional challenges can be explained as a neurobiological condition rather than a character flaw. They become motivated to seek and accept appropriate help to improve their professional and personal performance.
In this article, we aim to review what is known about ADHD in physicians, how to recognize the possible presentations of physicians with ADHD in the workplace, and how physician leaders can help guide these physicians in seeking professional help and make changes in the workplace if necessary. We hope that our clinical experience and observations of this hidden problem will spur discussion, awareness, and action by physician leaders toward further research and support for this niche population. In turn, this can improve patient care, physician well-being, and organizational functioning. Top
What we know about physicians with ADHD
ADHD is a neurodevelopmental disorder that presents as impairment in executive functioning with inattention, hyperactivity, impulsivity, and emotional lability/dysregulation inconsistent with developmental age.1 The Canadian ADHD Practice Guidelines (4th ed.) provides a comprehensive assessment and diagnostics framework.2
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) lists ADHD as present in most cultures in about 5% of children and about 2.5% of adults.1 Various reports suggest that a substantial proportion of children with ADHD grow into adults with continued impairment.3,4 Most ADHD diagnosed in childhood persists into adulthood, with persistence rates of up to 70% when using partial remission criteria.5 A longitudinal perspective of the disorder is warranted to truly understand ADHD and the phenotypic presentations seen across the lifespan. As a lifelong condition, ADHD has an impact in occupational, social, and personal areas of functioning. Thus, ADHD symptomology can persist or be diagnosed later in adulthood during medical school or in a practising physician. Top
Females with ADHD are often underdiagnosed and untreated, compared with their male counterparts.6 In fact, experts have suggested that this discrepancy results from a lack of recognition of the condition or referral bias in females with ADHD and have developed clinical guidelines to highlight the unique presentation in this group across the lifespan.7 Nonetheless, ADHD prevalence has increased among females across all age groups.8 These studies suggest that ADHD symptomology in female physicians may be more likely to be unidentified or untreated, present itself differently compared with males, and be more prevalent than historically measured.
To review the existing literature on this phenomenon, search terms, such as “physicians with ADHD” and “ADHD in physicians,” were used to search the Omni database, an academic search tool that gives access to high-quality resources from 16 Ontario university libraries. Of the 97 journal articles found, only three pertained to this topic. Inclusion criteria included any journal article from 1990 to 2021 that cited ADHD in physicians in the article title or abstract. Exclusion criteria included article titles that pertained to general adult ADHD, general ADHD with co-morbidities, and general ADHD treatment for both children and adults. References from these three articles were also scanned by two of us, but only one article was found by both that included ADHD in medical students. Top
A research study9 conducted among medical students in 2016 showed that ADHD was the most common self-disclosed disability: 33.7% of the 1547 students with disabilities. School-based testing accommodations were most frequently used (97.8%) and clinical accommodations were less frequent (34.8%). Testing accommodations included extra time to complete examinations (i.e., one and a half or double the time), environments with reduced distractions, and breaks. Clinical accommodations included leaves of absence, deferred clinical years, and releases from overnight call.
A case report10 documented the course of ADHD and its impact on resident training. It detailed the challenges faced by an anesthesiology resident (e.g., recurrent lateness, time management issues, task prioritization issues, and fixation on minor issues that were considered less important to patient care) and how educational accommodations, cognitive behavioural therapy, and pharmacological treatment had a significant positive impact on his performance of clinical work.
In another study,11 four recommendations were found to be helpful for psychiatry residents with ADHD: documenting the accommodations, ensuring confidentiality, measuring core knowledge, and not altering the core curriculum of the program. Top
Finally, a retrospective cohort study12 looked at medical students with and without disabilities protected under the American Disabilities Act to determine if there were differences in the effect of accommodations on medical admission test scores, clinical performance, graduation rates, licensing exam scores, and residency matches between the two groups.12 Clinical performance indicators included medical knowledge assessment scores, communication skills, data gathering, and professionalism across clerkships. Of the 59 students with protected disabilities, five had a diagnosis of ADHD. The authors found that in general, most students with protected disabilities performed generally well; however, compared with students without protected disabilities, these students were less likely to graduate and had lower academic scores.
Unfortunately, no studies on the impact of ADHD in staff physicians were found in our literature search. As the literature is so scant, we hope that our clinical experience can be a starting point for further investigation and action. Top
Recognizing potential ADHD in physician colleagues
Distinguishing between potential ADHD in physician colleagues and unprofessional behaviour caused by non-ADHD factors can be difficult. First, it can be challenging to identify patterns of hyperactive, inattentive, and impulsive behaviours over time and, instead, view them as individual incidents of problematic behaviour. Second, it is tempting to blame the symptoms on personality traits. Third, ADHD is often comorbid with anxiety, depression, substance use, and personality disorders.13 Fourth, symptoms or behaviours may be a result of other causes, such as burnout. Fifth, some physicians may overcompensate for their symptoms such as by spending excessive time at night completing their work.
The presentation of ADHD can vary depending on the environment. For example, hyperfocus is the ability to focus on a task for hours without interruption or breaks.14 A surgeon may benefit from hyperfocusing when completing a lengthy surgical procedure and have difficulty managing a busy clinic schedule that requires shifting focus repeatedly. The presentation of ADHD can also depend on life stage. For example, we have seen ADHD symptoms cause impairment when a physician takes on more responsibility, such as starting a family, changing jobs, or being promoted into management or leadership positions.
Tables 1, 2, and 3 outline what we commonly see in our practice and can serve as a guide. These tables provide explicit, clear, and descriptive examples of how possible ADHD-related occupational impairments can be observed in physician colleagues. Top
The strengths of ADHD
Although we have described the impairments of ADHD in physicians, ADHD symptoms can also confer many strengths. Our patients have been described as creative, “outside of the box thinkers,” quick decision-makers, passionate, big-picture thinkers, and entrepreneurs. These labels are a more socially appropriate manifestation of the same underlying emotional dysregulation and impulsivity. We have noticed that the hyperfocus symptom allows physicians with ADHD to thrive in particular medical specialties, such as emergency and intensive care unit settings. ADHD symptoms are conducive to fast-paced environments, high acuity, and the unpredictable nature of this work. This symptom can also be useful in medical settings that require long hours performing tasks that interest the physician, such as surgery. These symptoms/strengths allow physicians to be respected experts in their fields. Top
The role of physician leaders
Physician leaders can guide physicians with suspected ADHD to seek professional help, offer support, and reinforce coping strategies. Leaders can implement workplace accommodations, capitalize on strengths and help compensate for weaknesses, decrease the use of ineffective disciplinary actions, welcome neurodiversity, and promote mental health and well-being. Leaders can also advocate funding for treatment to help cover the costs of psychotherapy, occupational therapy, and coaching.
As with any colleague struggling on the job, it is important to try to understand their perspective rather than judge their behaviour. Our physician patients have told us that they are asked by management or colleagues to use simple strategies, such a planner or to-do list, or to complete a task right away, e.g., charting immediately after seeing a patient. However, they have stated that colleagues have made complaints against them without first seeking to understand. This approach fails to acknowledge the physician as a person with potential mental health issues and increases feelings of guilt and shame. Guilt and shame further impair performance, lead to worsening mental health, and create a vicious cycle. Top
We recommend opening up the conversation by describing the behaviours that have been noticed, asking the physician their thoughts on the potential causes, and stating concern for their mental health and ability to complete their job tasks. If the person is receptive, you may suggest that they might benefit from speaking to a mental health professional. This approach can help decrease potential defensiveness in the physician, maintain a safe and professional boundary, and lead to further exploration. For example, a leader might say, “I have noticed that you are easily distracted in meetings, lose things around the office, and have difficulty organizing your paperwork. Is everything okay? I am concerned about your mental health and how these tasks are affecting you. Perhaps we can talk further about your struggles if you’re comfortable sharing. May I suggest that perhaps speaking to a mental health professional might help? I read a paper on ADHD in physicians, which might be worth looking into and discussing with your doctor.” Top
As required by the Accessibility for Ontarians with Disabilities Act15 and the Ontario Human Rights Code,16 physician supervisors have the legal obligation to implement workplace accommodations and environmental changes. These can include, but are not limited to, setting up large digital clocks on walls to help with time management, providing checklists and templates, and reducing distractions by offering quiet spaces. Physician leaders can also reinforce coping strategies, for example by sending a friendly reminder on a task item, encouraging breaks and exercise, and developing and following a simple organizational system.
The clinical presentation of physicians with ADHD is often missed or mistaken for unprofessional behaviours, poor communication, and unsatisfactory work performance. Physician leaders are optimally positioned to detect, support, and accommodate physicians with ADHD in the workplace. Treatment strategies, such as connecting the affected physician with appropriate medical care and service providers in the community and providing targeted support in the workplace, will allow the physician with ADHD to thrive. With physician leaders aware of the hidden problem of ADHD, these changes will ultimately improve patient care, organizational functioning, work performance expectations, and social relationships. Top
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2.Canadian ADHD practice guidelines (4th ed.). Toronto: Canadian ADHD Resource Alliance; 2018. Available: https://tinyurl.com/n97xrhe2
3.Kessler RC, Adler LA, Barkley R, Biederman J, Conners CK, Faraone SV, et al. Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication. Biol Psychiatry 2005;57(11):1442-51. https://doi.org/10.1016/j.biopsych.2005.04.001
4.Sibley MH, Swanson JM, Arnold LE, Hechtman LT, Owens EB, Stehli A, et al. Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity. J Child Psychol Psychiatry 2017;58(6):655-62. https://doi.org/10.1111/jcpp.12620
5.Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2005;36(2):159-65. https://doi.org/10.1017/s003329170500471x
6.Gershon J. A meta-analytic review of gender differences in ADHD. J Atten Disord 2002;5(3):143-54. https://doi.org/10.1177/108705470200500302
7.Young S, Adamo N, Ásgeirsdóttir BB, Branney P, Beckett M, Colley W, et al. Females with ADHD: an expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women. BMC Psychiatry 2020;20(1):404. https://doi.org/10.1186/s12888-020-02707-9
8.London AS, Landes SD. Cohort change in the prevalence of ADHD among U.S. adults: evidence of a gender-specific historical period effect. J Atten Disord 2019;25(6):771-82. https://doi.org/10.1177/1087054719855689
9.Meeks LM, Herzer KR. Prevalence of self-disclosed disability among medical students in U.S. allopathic medical schools. JAMA 2016;316(21):2271-2. https://doi.org/10.1001/jama.2016.10544
10.Fitzsimons MG, Brookman JC, Arnholz SH, Baker K. Attention-deficit/hyperactivity disorder and successful completion of anesthesia residency: a case report. Acad Med 2016;91(2):210-4. https://doi.org/10.1097/ACM.0000000000000854
11.Elliott HW, Mayfield Arnold E, Brenes GA, Silvia L, Rosenquist PB. Attention deficit hyperactivity disorder accommodations for psychiatry residents. Acad Psychiatry 2007;31(4):290-6. https://doi.org/10.1176/appi.ap.31.4.290
12.Teherani, A, Papadakis, M. Clinical performance of medical students with protected disabilities. JAMA 2013;310(21):2309-2311. https://doi:10.1001/jama.2013.283198
13.Pallanti S, Salerno L. Adult ADHD in other neurodevelopmental disorders. In The burden of adult ADHD in comorbid psychiatric and neurological disorders. New York: Springer; 2020:97-118. https://doi.org/10.1007/978-3-030-39051-8_7
14.Hupfeld KE, Abagis TR, Shah P. Correction to: Living “in the zone”: hyperfocus in adult ADHD. Atten Defic Hyperact Disord 2019;11(2):209. https://doi.org/10.1007/s12402-019-00296-6
15.Accessibility for Ontarians with disabilities act, 2005, S.O. 2005, c. 11. Toronto: Government of Ontario; 2018. Available: https://www.ontario.ca/laws/statute/05a11
16.Human rights code, R.S.O. 1990, c. H. 19. Toronto: Government of Ontario; 2021. Available: https://www.ontario.ca/laws/statute/90h19
Mary Mammoliti, MD, FRCPC Psychiatry, is an adjunct professor at Western University, a locum psychiatrist at the Centre for Addiction and Mental Health (CAMH), and a community psychiatrist.
Christopher Richards-Bentley, MD, FRCPC Psychiatry, is a staff psychiatrist at the University of Toronto Health and Wellness Centre, Springboard Clinic, and the Centre for Addiction and Mental Health.
Adam Ly is a registered occupational therapist at an outpatient health clinic in London, Ontario. He is also an adjunct lecturer at the School of Occupational Therapy, Western University in London, Ontario.
Mary Nguyen is a fourth-year medical student at the Schulich School of Medicine and Dentistry, Western University in London, Ontario.
Sponsorship and funding: Dr. Mammoliti is paid through OHIP, hospital stipends, speaking engagements on physician health and wellness topics and independent medical evaluations. assessments. Dr. Richards-Bentley: Dr. Richards-Bentley has accepted speaker fees from Purdue, Shire, Janssen-Ortho and Elvium and Consulting Fees from Lundbeck. Mr. Ly is employed by CBI Health Group. Dr. Nguyen has no conflicts of interest to declare.
All authors equally contributed to the development of this article using their clinical knowledge, experience, and review of each other’s work. MN led the literature review and editing; MM and CB led in the recognition of ADHD in physicians; and AL led in the role of physician leaders, article structure and style, and editing.
This article has been peer reviewed.