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Shame and Medicine

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?