When I was in Medical School I distinctly remember rounding on patients to be its own form of torture.
Our attending was the persecutor and students were the victims. Vague questions were often asked in a rapid sequence, which is hard in itself, but the question asked would have so many possible answers… it was as though we were expected to read the attending’s mind to determine which of the possible answers applied to the question.
If a wrong answer was given, the response was dismissal, laughter, or other methods to humiliate us. As a medical student I was far from mastering the skill of thinking on my feet, accordingly, these moments usually left me feeling average to borderline dumb.
Even when I knew the correct answer, the connection between my brain and mouth didn’t always work, especially in our large rounding group. I learned to despise and fear these daily instances. I don’t think that there is anything worse than being made to feel as though you are worthless, which is how I felt a lot of the time.
While some of this is undoubtedly rooted in my own insecurities, I also believe that this approach is designed to motivate by making you fear failure and fear being a failure. This method of teaching continues to be alive and well in medicine, and may actually be present in other areas of society.
I now recognize this as a “shame-based” culture, in which the incorrect answer (the failure) is attached to one’s identity and makes one feel bad about themselves, instead of explaining things and encouraging one to try again. The issue is not the question/expectation or answer – it’s the response to wrong answers. This is a huge problem as it leads to less questions getting asked, less questioning of authority, less questions about therapies proposed by the supervising physician, and subsequently less learning.
This same form of ‘teaching’ continued throughout my training, always in a slightly different form, but maintaining the general format, and I continued to be anxious. There was never a feeling of safety or acceptance for lack of knowledge, which is crazy, because we were literally attending School of Medicine! We were all there to learn!
Having had time to reflect on my years in training and time to process how bad I felt during this period in my life, I’ve found myself passionate about changing the dynamic of shame in medicine and in my personal life. If you look around it seems shame is everywhere.
Brene Brown, researcher and NYT best-selling author does an excellent job of discussing personal shame in her research, her books, and her TED talk. Her insights really opened my eyes to the damage this way of learning, being, teaching was doing to society.
Constant shame creates a feeling of inadequacy and loss of connection with others. It is isolating and lonely.
In addition to reading Dr. Brown, I also came across some research that Google has been doing. Google has been studying teams for a long time (I am going to use teams and communities interchangeably here), and found, surprisingly, that the most effective teams weren’t comprised of all smart people, they weren’t comprised of only men, or only women, but it was the groups that felt ‘psychological safety.’ http://www.businessinsider.com/amy-edmondson-on-psychological-safety-2015-11?international=true&r=US&IR=T
This term, ‘psychological safety,’ has been defined as “a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes,” and coined by Amy Edmondson from Harvard Business School. It is an opposite of the shame culture.
When I initially read the article describing the idea of psychological safety, I was surprised it was so simple, yet so elusive.
As I mentioned earlier, I was ‘raised’ (ie my young professional career) in medicine, where there is virtually no psychological safety in the training of young doctors. If you are in a surgical sub-specialty, or you train in certain parts of the country, it is even worse. So, there is no lexicon even in medicine for this. If there is no place safety exists, then as one traverses from being a young trainee to being in a more senior position, the toxic environments of a shame-based culture persist, and one is then the owner and administrator of the toxicity.
There is no safety.
I lived in this environment. I was the scared medical student, the resident who didn’t feel as though I could do anything right. The fellow who was scared to always say what I thought, for fear of being wrong. It was hard, and it was incredibly lonely.
So, what does one do? How do you change the culture?
I personally realized that for MY working community, I needed to change. Let’s be honest, as a woman in medicine, we are taught to have an edge or no one will listen. It’s very hard to be a woman in a leadership position these days! I always wanted to be successful, but I wasn’t seeing results. I am a fairly nice person by default, but in challenging or stressful situations, I was using this nasty/hard-lined counterpart to push people to do what I wanted. It never went well. I also noticed I was particularly hard on medical students. I think it is because I was most mistreated as a student.
I decided to change.
I intentionally went into every shift with compassion and kindness, for my TEAM, my community. I made more efforts to have personal conversations with people, so I could see them more humanely.
What did I do?
I chose to respond differently. I pimped less, taught more. I didn’t get angry when tasks weren’t done, instead I gently reminded and explained why it was important. I stopped reacting to people and situations. I also became intimately aware of my habit of being judgmental. Because I was raised in this environment, we are then taught to have a lot of judgment around others’ performances. I consciously try to stop myself from those thoughts, as it can taint my attempts to teach.
These actions have notably changed the way I view my community at work–as a place I like to be, but also a place I feel as though I am effective. I think it is because I was able to create safety, and my teammates responded. I am NOT perfect, and will never claim to be, and sometimes, under the right circumstances, I slide back into old behaviors. But I am much better at recognizing when I do, because I lose my calm happy energy, and that doesn’t feel very good, so I try to get it back.
What about you? Have you experienced anything I have discussed? How have you managed yourself? How have you tried to change the status quo?
Again you hit the nail on the head. As someone who has dedicated the past 20 years to educating and training others, I am furious that the humiliation that you experienced under the guise of training. Humiliation and fear in learning produce a mild version of PTSD and decrease the learner’s ability process and retain the material (Perry, 2006). Furthermore, the long-term effects of fear and humiliation in learning are felt for many years after the experience (Perry, 2006). For example, people who had negative experiences in elementary school learning math experience a physiological reaction when asked to calculate a math problem as adults. Similarly, your experience shaped how you reacted to medical students who made mistakes.
Now having said that, I will admit that as a young educator training EMTs and Combat Medics, I utilized the same techniques you experienced in medical school. I attribute that behavior to a lack of knowledge of the long-term effects of humiliation and fear in training. Additionally, I was socialized through EMS and the military that that was the best way to teach. The emphasis was on inducing stress to judge if the student could think on their feet. However, there is a time and a place for that type of training, and it has to be done right for it work.
I am glad that you realized that you too were perpetuating the cycle of humiliation and fear in medical training and made a conscious effort to change. I will add that having worked at the same institution that you have for several years, the institution lends itself to a kinder gentler way of teaching and interacting with subordinates. However, it might have been more difficult to change had you worked at a large urban trauma center in the northeast.
An excellent resource for learning about Dialogue Education is one of my favorite books from graduate school, Jane Vella’s Learning to Listen Learning to Teach: The Power of Dialogue in Educating Adults. One of the most interesting concepts that I took away from that was the differentiation between dialogue and discussion. Discussion is the active process of talking, usually in order to reach a decision or exchange ideas. Dialogue is the process of exploration and discovery through open questioning between two people (i.e., Di Greek prefix for 2).
Lastly, I will end with one of my favorite quotes about good teachers.
Good teachers, “…have a quick, sure and unflagging sympathy with … the minds they are in contact with. Their own minds move in harmony with those of others, appreciating their difficulties, entering into their problems, sharing their intellectual victories” – John Dewey
Perry, B. D. (2006). Fear and learning: Trauma-related factors in the adult education process. New Directions for Adult & Continuing Education, 2006(110), 21-27. doi:10.1002/ace.215
Thank you Max for such an insightful and interesting response! It is interesting to hear the stories of teaching EMS and military, and to understand it is not that different than medicine. I also wholeheartedly agree with you, that where you work can have a huge impact on whether or not you can come to recognize the trauma you are precipitating on others. I’ll be interested to read your reference as well as the Jane Vella book you recommend! Thanks for sharing!
I got a little long winded, but it is something that I care deeply about.
I appreciate the passion! Partly because I feel the same!
I chose the med school I went to for its pass/fail system. To try and avoid some of this. But at that very med school… which I graduated from with honors in every one of my clinical rotations… one of my few female surgical attendings once called me a “nitwit” for daring to acknowledge that I wanted to be a pediatrician while doing my surgery rotation. I got honors from the other surgery attendings during that rotation. Because I worked my ass off. But it was quite the moment and I still can’t shake it.
Oh Denise, I completely understand! It’s like Max pointed out, humiliation and fear in learning produce mild versions of PTSD, that we have a very hard time shaking. I believe I had PTSD from training that only NOW, 9 years later, I am processing and releasing. But these experiences definitely stick with you for a long time. It’s why it is so important for us to recognize the pattern, so we can hopefully stop the cycle.
Very thoughtful and poignant assessment of the toxicity that can be part of medical training. Thanks for being present and mindful. Your attention to deliberate practice is not only benefiting your learners but most importantly your patients. The ripple effect is tremendous as the impact spreads exponentially through your learners and those they come in contact with.
Thank you Charmaine!
The problems that you faced in medical school are similar to the ones I had in the Canadian residency training; in some rotations having almost symptoms of physical illness when “teaching rounds” were coming up. Recently we had a discussion in the Medical Genetics Residency Training Committee meeting exactly about this same issue. Some years they had difficulties filling their residency positions because their reputation amongst residence is so poor. The Program director came up with an idea and sent out a resident newsletter to all faculty, which I copied below. I have never heard of the notion microaggression before, but here it is:
“The concept of microaggressions is receiving a lot of attention in health care and education. Microaggressions are the comments, behaviours, or environmental aspects that undermine intelligence and competence of recipients. Microaggressions can be intentional (ex. to communicate a teaching hierarchy) or unintentional (we all have biases we’re not fully aware of!). Receivers, especially when in a leaner role, can feel powerless to do anything, leading to mounting stress and disengagement (Souza’s Magna Webinar, 2018; Suarez-Orozco et al., 2015; Sue et al., 2007). All teachers should be able to:
• Describe and provide examples
• Learn to recognize when we are perpetrating
• Find ways to create a learning environment which limits microaggression, and to respond when microaggression is witnessed.
These objectives are addressed in Souza’s Magna webinar, which we have available for viewing upon request via VFMP Faculty Development.”
Unfortunately we are not sure if the ones that it was intended to, will recognize themselves as the perpetrators. It is not easy to talk to a colleague about it , when you know that it is a problem.
I can only commend and admire your insight, attitude and the willingness to change!
Thanks Gabriella! So fascinating that the culture spans to other countries. I find the idea of those in power perpetrating microaggression SO interesting. I hadn’t thought about it like that! I think it is very true that we could be doing these microaggressions due to implicit bias that we aren’t even aware we have. Another reason it is so important to ‘check’ how we behave with others, and then maybe reflect as to why a particular person/resident/student coused us to feel threatened, angry, hostile, whatever. Thanks so much for the incite!
This is such an important topic and I am glad it is being brought to light. It often likens to a toxic relationship between physician and medical culture. This is probably why most physicians keep their head down and continue despite conditions that people from other careers look at in shock. It is up to us to be more vocal about it and come up with ways for positive change. As physicians, we can do so much good and help so many. It’s time we help ourselves too.
Thanks Nadia–this culture totally manifests itself as an ‘abusive relationship,’ where we are beaten down, made to think we need to work really hard in terrible conditions to succeed. And then we perpetrate that behavior onto others. We need to be able to rekindle the part of us that you speak about, usually its the reason we went into medicine, and try to advocate for ourselves, and abolish the toxicity.
Annie, thank you for much for these. This is so brave and I know how hard it can be to admit when it needs to change. This blog is such a lovely resource, and not just for medical professionals. As a teacher, I know I also have remember not to be judgemental when one of my students isn’t able to magically read my mind and give the answer I was looking for. You’re totally right about this shame culture and it’s permeating throughout every professional field. There’s always a teaching moment, and thank you for reminding me. You are an inspiration.
Thanks Cori for the comment! I truly forget sometimes that there is a world outside of medicine! BUT it totally makes sense that the tools here, ie trying to abolish shame culture, could apply in the regular school setting as well. Thanks for sharing, and I am so glad it has made you think about things a little different! 🙂
This article was a very painful walk down memory lane. It’s no wonder the “other healthcare crisis” — physician suicide on the magnitude of one entire medical school (400+) every year — starts with medical students, interns and residents. It’s so important that we flip the script and direct the spotlight of shame onto the institutions that perpetrate this heinous practice.
Thank you Dallas for sharing. I agree, I think for a lot of us, this type of practice is all-too-familiar. I agree as well, that our current crisis of physician suicide is rooted in our shame-based culture.
Wow- this brought me right back to the terror felt on rounds. You are right that this shame-based culture in medicine directly interferes with the learning that is meant to be happening. It was especially humiliating to be pimped in front of patients!
Thanks Melissa! It is absolutely humiliating in front of patients!
Sooo true keep them coming
Thanks Nana! And thanks for reading!
A thought provoking read. Agree 100%. I don’t want trainees to have PTSD like most of us do about our training.
Thanks Halima. We totally need to figure out how to change it!