Silences in the System: A Scoping Review Examining How Medical Education Literature Shapes Neurodivergent Learners' Pathways.

Neurodivergent learners represent an estimated 15-20% of the population, yet medical education has been slow to create environments where learners feel safe disclosing neurodivergence. The literature on neurodiversity in medical education remains fragmented, with limited attention to how institutional structures and dominant assumptions shape which learners are rendered visible or invisible in research and practice. To critically examine how the medical education literature describes neurodivergent learners and their pathways to professional legitimacy, and to identify patterns of presence, absence, and assumption that reveal which learners and experiences remain at the margins of inquiry, we conducted a Critical Interpretive Synthesis informed by scoping review methodology, using a critical epistemological orientation that foregrounds equity, power, and epistemic inclusion. PubMed, Scopus, and CINAHL were searched, yielding 28 included studies. Analysis examined both what the literature reported and how it framed neurodivergence, attending to significant silences as findings about the field's epistemic boundaries. Themes identified focused on diagnosis and disclosure as gatekeeping mechanisms; institutional culture as barrier to legitimacy; assessment structures as sites of exclusion; psychological burden of navigating neurotypical spaces; and support as reactive and individualized. Additionally, themes that appeared on the margins of inquiry included: intersectional silences regarding race, gender, and socioeconomic status; disappeared trajectories beyond undergraduate training; and limits of structural critique that question systems rather than individuals. Only four (14%) studies explicitly examined racial and ethnic demographics of neurodivergent medical learners. Medical education scholarship constructs neurodivergence primarily through deficit-oriented, individually focused frameworks while rendering invisible learners at intersections of multiple marginalized identities. Advancing equity requires shifting from reactive accommodation toward proactive institutional transformation that questions normative assumptions about competence and professional belonging.