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Emily Silverman

Thanks for listening to The Nocturnists’ Shame in Medicine: The Lost Forest. If this is your first time tuning in, welcome, and I actually recommend you rewind and start at Episode One. This is a series that builds on itself over time, so starting at the beginning will definitely lead to the richest listening experience. Enjoy the show. You're listening to The Nocturnists’ Shame in Medicine: The Lost Forest. I'm Emily Silverman. Over the last nine episodes, we've listened to dozens upon dozens of clinicians tell their stories about shame. But in today's finale, we wanted to let the series fold back in on itself, and take a pause to sit with everything we've heard. What have we learned? What can we take away from all this? First we'll hear from a hospitalist in North Carolina who reached out to us, out of the blue, after hearing the second episode of our series in her car. Something about the episode really struck a chord with her, and she almost didn't reach out to tell us this, but ended up having some coffee with friends who insisted that she send us an email. And we were so glad that she did. Next we'll hear from a couple of the clinicians who contributed their shame stories to the series about what's changed for them since. Then we'll circle back to Will and Luna (our shame experts) with some reflections and lessons learned from the project. And then, finally, we'll talk to Corinne Conn, a medical student, who contributed their story to our episode on shame and testing, but who also helped us produce this series, and we all think probably has the clearest understanding of anyone on the team of what we were trying to do here. So, without further ado, let's begin on the open road in North Carolina.

Jenny Hinson

I was driving to a conference. It was a bright, sunny day and I was driving through the countryside. And I had, like, an hour's drive. So, like perfect time to get the second episode of your podcast. And listening to this story about another physician who had experienced getting sick at work... and she started describing an event that reminded me of my own. I initially was focusing on certain details that she said, like her chief resident came in to finish the shift for her. So I was initially focused on things like that, like, I guess, feeling a little bit jealous that the only person that helped me was my other resident, who took me into another room, and put an IV in me, and gave me fluids. And, I think, while I was hearing her story, I had this image of myself when I was working as a resident, care in the public hospital of some little back ER room, sitting on a stool because I was too dizzy to stand up . And thinking "How am I going to examine this patient?" Because I have to stand up to examine them. And feeling terrible, because, gosh, what if I give him what I have? And I'm not doing him any justice, but I don't have any choice in the matter. And, at one point, I think it was maybe when she said something about needing to be superhuman, I just started sobbing out of nowhere. I,... I mean, it astonished me! I couldn't stop crying; I had to pull off the road, because it's all messy. I had to, like, dig around the car to find some tissues. I could not stop crying. The very strong emotions really surprised me. I think they came out of me, of being able to see myself in that story, and have some empathy for myself. And I think, maybe, that was what clicked the light bulb to go: "Wait a minute. This is a lie that you've bought into; that you maybe weren't smart enough to be a doctor, but if you just sacrificed really hard and fought really hard, maybe you would be good enough." If you'd asked me before if I'd thought that, I would say no, but I kind of believed that whole thing about needing to be superhuman, and not ask for help, and it's not okay to be sick. I saw this person, who was trying desperately to do her job, but didn't have what she needed to do it. I ... Yeah, I wanted to tell her, "You're being asked to do something that's not possible. And it's... You're okay like you are, and it's okay if you haven't figured that out yet. But as you figure it out more, you'll be able to bring even more to the world." I guess I'm still figuring it out; I don't have a great way of saying that, but... I would have told you that I was pretty, pretty confident in who I am as a physician and to, sort of, realize that I still had those insecurities and false beliefs about myself was really eye-opening. I didn't even know those things were still in my head after all this time. Hey, Drea; it's Emily.... Hi, Josh. This is Emily from The Nocturnists.... I just woke up, which is why my voice sounds like this. Forgive me.... So nice to meet you over voicemail... So first, I wanted to say thank you, again, for submitting your amazingly powerful story.... Obviously, we're all different. We're in different parts of medicine. But the story you told to me just felt really universal, and so... I wanted to just check in, and see how you're feeling about having your story included in the series... Second reason I'm sending you this message is about the series finale. What we would like for the finale is for people who sent us their stories to reflect on, comment on, what was it like for them to share their story? Did the act of sharing the story impact you in any way? Was there anything about sharing the story that actually impacted your experience of shame around that issue, or not? So, anyway, I've been rambling for way too long. But, if you would be willing to just record yourself for a few minutes responding to this message, maybe responding to some of those questions that we had, that would be really awesome.... And I hope you have a wonderful beginning to your summer. Take care, bye.

Drea Burbank

Hi Emily, I'm actually in the middle of the Colombian Amazon. You might be able to hear some of the insects in the background. This story about class came out so suddenly. I just started talking and then this fully formed analysis came out. And, you know, the weird thing is, like, I didn't know it was in there. You know, it was twenty years of, like, processing. But, I'm not sure if it was just the right thing at the right time. I have a theory about storytelling and healing, and it's that it's not a story until it's healed. When this was initially happening, I felt deep, deep, shame. Silence. I didn't want to acknowledge it was happening. A lot of fighting back. And I talked to people about it at the time. I talked to my classmates and stuff, but it never came off as something they could listen to. I think it was just too raw. Like, I hadn't processed it at all. It was just way too hot. It was like heated metal that hadn't been tempered, or cooled, or turned into steel yet. I personally think, right now on my journey, that trauma can always be metabolized into something more beautiful. And when I look at the work of fine artists, you know, excellent writers, amazing political activists, a lot of times I think what I'm seeing is just their hard stories, their shame. Like eatin where the Chinese Qigong masters talk about eating Shun, which is, like, this negative energy that accumulates in your body from pain. And then if you eat it, it turns it into gold. It's like this... Maybe it's the original form of alchemy. But, I know that when I first talked about my issues, it seemed angry. It seemed vindictive; it seems like an excuse. I could not speak about it clearly. And with distance... Until I had eaten my own "shen". Our stories have a process, you know. They're not meant to be shared prematurely, perhaps. But when we do share them, and it's the right time, they can be profoundly healing for other people. But more importantly, it's profound. Like, it closes the loop on it in your own mind, because,... like, you can finally let it go.

Josh

I would say the overarching feeling I had when I initially recounted the story of what happened, and what it felt like, I mostly felt anxiety, embarrassment, isolation, second guessing. You know, if I didn't have a place to go to talk about that, where I know that the two men that I hang out with regularly now on Monday nights, who have similar stories to be told, will provide nothing but love and safety for me to be me, in the stories that I'm telling. And that has changed my life. It's still scary; there are definitely times where I still feel like they're gonna get tired of me telling another story. They are gonna laugh at me or get bored with me or tell me to grow up and just gut it out: "Life is tough." But up to this point, three years into our continued, sort of Monday night ritual, that hasn't happened. Finally, I'd say, what I've had to learn, in a hard way, is, I thought maybe after six months, or twelve months of engaging with heartache and a poor outcome, I thought it would just go away. And I would just stop remembering, and stop feeling bad. And just move on. And, in all honesty, I just haven't found that that's true. I still have memories that pop up every now and then about the birth that I described. I'm not sure that that will ever go away, if I'm really honest. The question is how to move forward. The way forward - if I'm going to to continue to do this work - is to have a space where I feel connected and loved by people that know the "ins" and "outs" of my story, and they still accept me, in ways that make me more of me.

Emily Silverman

So, Will and Luna, we've all been asking ourselves: What surprised us about this series?

Will Bynum

What surprises me about the series is some of the repetition, actually. It's some of the fact that it wasn't surprising, because it means that these experiences are probably very pervasive, rather than this being some sort of a small sampling of people who are willing to come forward about their shame, and they're in the the vast minority of people in healthcare. I think that this is an "iceberg" phenomenon. These are the people that were just courageous enough to share it on a podcast, openly.

Luna Dolezal

I think I was surprised that so many people were willing to come forward and share their stories. That was really heartening. I think hearing these stories can be profoundly transformative for others who maybe connect with the themes of their stories, even if they themselves haven't shared their own story. And, it's not that I hadn't ever thought of that. It just... I guess, in our research projects, we ended up having really discrete topics that we investigate deeply and sort of leave everything else to one side, and this is just much more comprehensive.

Will Bynum

Comprehensive is a good word for it. What's kind of remarkable is that we didn't put out a call for stories that had these ten topics in mind. We just said "Send us your stories of shame in medicine." And, we came up with at least ten topics. There were many more that we could have expanded upon. And that's, ...that's really incredible to think about how much in our profession this emotion touches or can touch. And no research study, no single research study, can begin to contemplate that level of breadth. And I think this series has really done that. We've heard about shame, that arguably is unavoidable as you go through a career in medicine, and we have to be able to accept that inherent experience of shame, and work through it in constructive ways. But we also have a lot of stories about shame that did not have to happen, that is a product of a system that is not aware of the shame that's happening. And through that lack of awareness, is inducing it unnecessarily in a lot of ways. We have to engage with this emotion more openly, so that we can change the shame that we're inducing on people.

Emily Silverman

There's a lot of talk about vulnerability Brené Brown popularized this idea that vulnerability is strength. But we've also heard from people in the healthcare community that there are certain people who just can't be vulnerable, whether that has to do with who they are, or their identity. So I think we need to be careful when we talk about vulnerability as, like, the path to, you know, freedom from secrecy and all of that, because it may not be available to everyone. So I'm wondering how the two of you think about that.

Luna Dolezal

Yeah, that's a really good question. It's important to be vulnerable, but to be vulnerable in a way that doesn't leave you raw or open to more distress. And that's the kind of journey that each individual has to take for themselves, to understand the contours of their own experiences and their own shame. And there are some shame experiences, I would speak really openly about and turn into funny stories and others, I would never, ever share.

Will Bynum

As we've done this series, I've constantly listened to these stories and thought about what it must have been like to pull out a microphone and tell your "shame" story, (some of which are so personal), upload it to a computer and hit send. And then, off it goes, you know, into the internet. What an act of courage that is. And at the same time, there may actually be some safety with the anonymity that can come with that. And it actually may be riskier and harder to show up in person into some of our environments, and do the same thing. And so, I think we have such a long way to go in healthcare, in terms of facilitating what's required to be vulnerable, so that it no longer is an act of courage, but it's just a sort of a routine action we take.

Emily Silverman

Speaking of surprises, I was surprised when we put out the call for shame stories initially, and almost all the stories that flooded in were from women. And we actually put out a second call for stories that was specifically targeted toward men, because we were looking to fill that gap. And in the end, after all of that, still, 75% of our stories came from women. So, I'm curious what the two of you think about that.

Will Bynum

I'm not surprised – partially because, as a man, I know somewhat firsthand the risk of being vulnerable, showing emotion, particularly shame, and how that might undermine the masculinity on which my self-concept relies, at times. I also am not surprised because over, now almost ten years of doing work around shame, this is a common trend. Whether it's the attendance at a workshop that I put on, recruiting for a panel of speakers, recruiting for a research study, this podcast... Almost always, there's a predominance of women. And eerily, it's around 70 to 80%, which is exactly what we experienced in this podcast. I don't really know all the reasons why. What I do know is that there is something going on with shame and men in medicine. There's something significant about this emotion and about being a man that is present in our current healthcare culture. Given the fact that medicine has been a male-dominated field, particularly white men, and given the fact that men hold most positions of authority and power in medicine, what is the function and effect of all this shame that is either not being experienced, or more likely is not being talked about, dealt with, shared, lived through, among this really critical population in health care? And the last thing I'll say is that the apparent hesitation, or inability, or challenge, among men of dealing with shame, or talking openly about it, or engaging with it... to me, makes them a vulnerable population.

Emily Silverman

Will, you said something earlier about how you suspect that these stories are just the surface of an iceberg. And one of the consequences of working on this series, for me personally, has been that I just see shame everywhere now. Has that been happening to either of you?

Luna Dolezal

I always, kind of, think of, like, once you understand shame, and the common defenses and defensive scripts we have to deal with shame, and understand how powerful it can be to motivate behavior, or how we can organize our interactions and even our whole lives around shame avoidance, then it's kind of like you have the code. Like, you can decode a load of stuff and start to see below the surface. And you can do that on like an interpersonal level in the interactions you have with people, but also on a societal level, on a political level. You start understanding that governments and nation-states are... All they're concerned about is reputation management and saving face. You start to see this kind of fundamental human pattern everywhere. And that's really powerful, I think, to have that understanding, because then you understand this kind of common connection that we all have is that we all want to be accepted, loved and connected to others. We all want to feel belonging. I mean, I do kind of joke that everything is about shame.

Will Bynum

I kind of think of it like putting on these special glasses that give you, like, this X-ray vision that allows you to look, maybe one or two or three, steps or layers deeper than what you're encountering from a person. And you never really know, so there are some assumptions that come. But given how ubiquitous shame is, having those X-ray goggles makes me more empathic I think. It allows me to anticipate better how someone might react to a certain situation.

Luna Dolezal

Having "shame competence" can only make you do better in your job, if a fundamental part of your job is interacting with other human beings in situations where they might be feeling distressed, or have some need... some need from you. So, there's a kind of fundamental emotional intelligence that I think all clinicians need to have. And shame really should sit at the heart of that.

Will Bynum

I always recoil a bit at the notion of being an expert at shame, because I really feel like we're all experts in shame because we all feel it and experience it. We just analyze it more.

Emily Silverman

Hi, Corinne.

Corinne April Iolanda Conn

Hi.

Emily Silverman

So Corinne, what did it feel like to sit down, record your story, and hit "send"?

Corinne April Iolanda Conn

First off, I felt the old anxieties come right back. In the next couple of days, I felt better. But there was work. I have even more perspective on that now, in relation to that, kind of, boot camp challenge; learned how to feel as if, even if I'm not engaging with all of the priorities that I have in life, when I have to kind of hibernate, so to speak, and go into Terminator mode for the Step Two, and like I will for the Step Three, there is a...there is a difference in my stance. It's almost like a yoga pose: where maybe I was holding Mountain Pose, and it really wasn't helpful to hold Mountain Pose through Step One... that I had now discovered, like, you know, the Swan. And the Swan works pretty well for these exams. So, I think, at least for me, I think that's been one of those, like, encouraging and hopeful outcomes of having to go through it and then go through it again. And then do it again.

Emily Silverman

I love this description of the yoga poses and what you said of now I feel like I can kind of go into Terminator mode and come out of it. And what you're describing is really an internal change. So, nothing external really has changed. You're still a medical student; you're still running this gauntlet; you're still taking these tests. The tests themselves haven't changed overnight, and yet you're having this completely different experience of the test. So what is the difference between Mountain Pose and Swan pose? What is the internal experience of moving through these tests now, compared to before?

Corinne April Iolanda Conn

One of my best friends, after Step One had passed for all of our class... And what he said in response to the way I describe, like, reading each case vignette for every patient, and how I would approach it with almost, like, my head and my heart. So I would read something like: "Oh, this mother's child passed away in a car crash, and then she had bla bla bla test results. And what drug do you give her now?" is like the... broadly what would occur in a vignette. And I would sit there and in that one and a half minutes of reading it, I'd have thought: Oh, no! What happened to the kid? Like, how's the family doing? And all those questions are irrelevant to the task, or what I was being asked by UWorld. And so my friend said, Corinne, you brought, you brought gold to this land heap. It didn't need it; you brought all your ingredients in the kitchen to cook. And all this needed was what it was asking for. And so, I do think, in a way, Mountain Pose was like me showing up as all of myself for, honestly, a test that really required only one part of myself, which is my memorization capacity and pattern recognition. And so I find that Swan pose allows me to, not necessarily dissociate from all parts of me, but it allows me to channel and highlight one part, without feeling that I let go of the presence of other parts of myself for these tests. It just has become a necessity, because of the sheer volume of suffering I now interface with, that I can compartmentalize.

Emily Silverman

So Corinne, when you listen back to your clip, what do you hear in your voice?

Corinne April Iolanda Conn

I hear a lot of disgust around, not just the fact that it exists or that it's such a, like, that the setup of it is such a huge part of the process of becoming a physician. But I think I also hear the anger that I internalized some myths and so many things that kind of, like, set me up for such a struggle. And that... disappointment in my self, letting go of my kind of step-by-step mantra for this "you are not enough" narrative. I sense that shame actually, in it's not just the shame of failing Step One that's in my story, it's the shame of being affected by something that's so material, when I have a strong, like, value, as a spiritual being, as a spiritual person. That there are...there are so many things that matter more in life than a number. And I let it get to me; I let the number get to me. So I definitely think talking about it, over and over again, rewriting my own narrative around it, and how I orient to it, has helped me get to that stance that feels far more like myself.

Emily Silverman

Now that this storytelling series exists, what do you imagine as a next step? Is storytelling enough? Is there some other type of intervention that we need as a culture? Is it even possible to design and implement an intervention for something like this? Or is it really just a bottom-up inside-out transformation that has to happen through storytelling?

Corinne April Iolanda Conn

Asking whether sharing is enough is a question that I can only answer by remembering that our world, at this point in time in human evolution... We seem to evolve fastest with an idea, with a thought, right? Our technology can do whatever it's doing. We don't need years of genetic, like, mis-matching and replacements to see something new. We literally create change through a thought that gets coupled with action. So when I think about sharing a story, and following it up with very organized, thoughtful, mindful action, I feel almost guaranteed that something more beautiful and healing is going to occur. But for the purposes of changing cultural narratives or changing the way we operate, I do think sharing is more than enough of a seed.

Emily Silverman

Thanks for listening to The Nocturnists’ Shame in Medicine: The Lost Forest. Our team has learned so much from putting this all together, and we're really glad that you came along for the ride. While this is the last episode of the series, it's really only the beginning of what we hope will be a movement to change the way we think about shame and medical culture. We hope you'll return to these episodes again and again, because there's just so much here. And, speaking for myself, I know I hear something different every time I listen. I also encourage you to check out our website at thenocturnists-shame.org where you can find so many great resources. There's a portal to submit a written or recorded reaction to the series, and a forum where you can see what other people are saying. There's language that you can use to spread the word about the series to your friends and colleagues. There's a facilitator toolkit and discussion guides for each episode. For those of you who would like to host a conversation about shame in your community, whether it's a casual thing like going over to someone's house to talk about this stuff, or something more formal, like a noon conference. There's information about how to invite somebody from our team to come and speak at your institution about Shame in Medicine.

And, just a quick plug, we're actually really excited to already have been accepted to present our work at SXSW next year in mid-March. So, if you're in Texas, keep an eye out for that. There's a place on our website where you can claim CME credit, because who doesn't love a bunch of CME points. And there's a section in the website where you can check out additional resources for study, whether it's books, articles, essays, videos,... just a ton of resources if you want to learn more about the theme of shame. To the storytellers, I just want to reiterate again, and I know you're probably sick of getting emails and voice memos from me, ... but, thank you so much for making this series possible.

At The Nocturnists, we really view our work as an act of co-creation, where we toss out a prompt and then hear back from our community and we use your responses and your stories and whatever it is that you say to put together the show. Even Luna's initial email, asking me about the topic of shame, was an example of this, and that gave birth to this entire project. So, I really encourage you to just keep listening, and if you have an idea or a thought, or a story, reach out to us because.... who knows where it could go? People often ask me: Who is the audience for The Nocturnists? And I always say the same thing, which is that the show is a love-letter to healthcare. Certainly there are people outside of healthcare who are welcome to listen, but we really make this for you. So thanks for letting us do that and for opening up to us. We are so, so grateful.