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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, I recommend that you rewind and start at episode one. This is a series that builds on itself over time. So we think that starting at the beginning will offer the richest listening experience for you. Enjoy the show!

When I was a medical student on my surgery rotation, every time I went into the OR I felt like I was being watched. There's this very involved scrubbing process where you have to wash your hands down to your elbows, and then put on a gown in a very specific way, and then twirl and have it be tied and snapped in a certain way. And as I went through these motions, it felt like the scrub nurses were watching me like hawks and just waiting for me to make a mistake. And when I did make a mistake, even a small one, like just stepping an inch too close to a tray of instruments or bumping my butt against something, they would tell me to go outside and try again, go outside, try again.

And then, once you're in the operating room, you're surrounded by these men. They're shooting the shit, talking to each other over this anesthetized patient. And sometimes it's a good-natured, sort of poking fun at each other. But sometimes even the attending would say demeaning things to his learners. People would laugh, but I'm not sure they really liked it. And my instinct was just to be as small as I could.

And so that's my headspace when the attending turns to me and says, “Medical student, sew this wound.” And he hands me a needle. And at some point during the sewing, I felt a prick on my finger. And I looked at my glove, and I couldn't tell if I had actually poked myself or not. I did not see a hole in the glove, I did not see any of my own blood on my hand. But I had definitely felt something. But I remembered that what you're supposed to do if you stick yourself, or even if you think you stick yourself, is to stop what you're doing, walk over to the sink, wash your hands with soap and water, and then call the needlestick hotline and await further instructions. But I couldn't wash my hands. I was scrubbed into the OR. I was knuckle deep in this patient's body, surrounded by surgeons, blocked on all sides. And it didn't even occur to me to speak up and say, “Hey, I think I stuck myself. I'm going to step out.” Like, that was just not a possibility. There was no way I was going to interrupt this very important surgery with these very important surgeons. And so I just kept sewing.

And then, when the case finally ended, I took my glove off. And I washed my hands, and I looked at my skin, and I couldn't see an obvious wound. But, again, it was a pretty small needle. So I decided to call the needlestick hotline. And the person on the other end of the phone, they said, “Give me the information of the patient.” And I did that. And then they said, “Now we're going to send a bunch of tests on the patient's blood to see what they have so that we know what your risk is.” And the first words out of my mouth were, “No, no, no, please don't do that.” And they said, “Well, why not?” And I said, “I don't want you to order any extra tests on this patient. Because I don't want these surgeons to know.” I was imagining it in my mind. I was imagining Dr. X opening the chart, seeing that these extra tests were ordered, and then turning to the person next to him and saying, “Who ordered these tests on my patients? Why were these tests ordered?” And then all of the residents looking at each other and saying, “We didn't order it, we don't know why.” And then, them embarking on this, like, quest to figure out who ordered them and why. And then finally finding out that it was the stupid med student who stuck herself during surgery and now had to order these extra tests. It seems so silly now in retrospect. But it was a really strong and visceral reaction. It was like I didn't want anyone to know that I had done that. At the end of the day, I did let the needlestick person go ahead and order those tests. And I never heard anything from anyone.

Today, we're going to hear stories about shame and learning. We'll hear from someone who lost the trust of their senior resident, someone who suffered mistreatment on the wards, someone who was punished for not knowing, and someone who intentionally used shame as a way to try to help a learner get better. You're listening to The Nocturnists’ Shame in Medicine: The Lost Forest. I'm Emily Silverman.

Alexander Reuben Markes

I am a first-year orthopedic surgery resident in the west. I had a patient who had a very complex surgery, whom I discharged, and I did not discharge with the proper prophylactic anticoagulation therapy. And then a day later, the patient re-presented for chest pain with a low-grade fever. And we had to rule out a pulmonary embolism or a blood clot. Fortunately for the patient, then, they did not have a PE and they were discharged with the appropriate medication.

That did not stop the attending from probably having a stern discussion with the chief, and definitely the chief having a stern discussion with me. I remember it was, it was, you know, eight o'clock on a post-call day, so I hadn't really slept the night before. I was spending time with my fiance as this whole process was evolving, as the patient presented to the hospital and was being ruled out for a pulmonary embolism. And so I remember my girlfriend and my roommates were in the common room eating dinner. We were watching a movie. And I get called. And, you know, I took the call knowing something bad was probably going to happen. Not very often do you get called in your post-call day, and usually when you do it’s not something great. I stepped away to the bathroom that was just down the hall. Anyway, he proceeded to ask why I didn't prescribe this medication, and what was I thinking, and asking me to walk through the exact process of how I discharge patients. And, you know, after me not being able to tell him exactly, you know, where the error went wrong and, you know, why I chose to make this decision, he had brought up this prior incident that happened this week, where the patient had almost transferred to our service. And I distinctly remember him saying that I can't be trusted to make decisions anymore, and the conversations somewhat ending in that way.

And I, I hung up the phone, and I just, I sat in the bathroom for, for awhile. The smell of the bathroom when I was just sitting on the toilet with the seat down, with my head in my hands, you know, the, the stain of the days-old toothpaste that was on the sink, tearing up and crying as the weight of, you know, a month of intern year had set on me. Eventually my girlfriend came into the bathroom and consoled me. And much later she would tell me that was the first time she'd ever seen me cry. And I definitely spent a lot of that night convincing myself that I did know how to be an intern and I would be okay. And then I'd have to walk in the next day and, and take call with this person and look him in the eye and still talk to him about patients, knowing we had this very hard conversation the day prior. And it’s something I think about, even to this day. I still have this fear, a little bit, when I receive texts, not because I’ve done anything wrong, but maybe because it’s just very triggering. I think in the scheme of things people have much worse things that happen to them in medicine. And I haven’t really told this to anybody because it’s probably, like, “Oh you should just get over it,” type of thing. But the stress of trying to prove to myself that I knew how to be a physician and could be a physician, and, you know, being told by my chief that I cannot be trusted to make decisions in the care of patients–just all that night. This symbolizes, probably, the lowest point of my residency so far, and there might be lower points too. But it's, you know, it's something that I've had to try to forget.

4th Year Resident

I'm a fourth-year medical resident in Canada. And my story begins when I was a third-year medical student. And it was my first rotation in the hospital. I was on an overnight call down in the emergency room. It was an odd hour of the night. The full-blown bright lights aren't on so it was kind of this dim, dull, hazy blue, almost like you're sleepwalking a bit. And myself and my preceptor were in the back of a physicians’ nook. My preceptor asks me, okay, I want you to interpret this ECG for the patient that I just saw. So I take the sheet, and I'm staring at it. My brain is tired. And I really am not very strong with ECGs at this point. It really does look like a bunch of squiggles to me. So I say, “I don't know, I'm not sure what this is.”

And she launches into berating me, saying that I should have known this. And the fact that I didn't know this was a really, really, really bad sign. And, who knows, maybe I'm a useless case. They're just going on and on. And it wasn't even in a private setting, it was very much open to everybody else who was in that space. But nobody came in. And I can feel my cheeks and ears go really red, I feel quite stuck. I don't know what to do. And I can't really go anywhere. We have to finish admitting this patient. So I'm going to try to melt into the back of the chair and disappear. But definitely that started in my mind this narrative of, “Am I even smart enough to be here? Is this the right place for me? Did I make a massive mistake?”

As the week was progressing, I noticed pretty quickly that I was being treated differently than the other medical students. They're coming and going, but I'm just constantly being assigned more and more admissions. And for that week, she essentially had me doing all the admissions, such that I couldn't really go upstairs to round on my patients. And it came to a point where she reassigned my patients to the other learners in that group. And then I was kind of there alone and I just felt so miserable. And I remember I broke into tears when my parents came and picked me up that evening. I wasn't sure why I was being picked on or made to do that. I felt this preceptor was clearly targeting me. And this is my, you know, first inpatient rotation ever. And that's, I think, when thoughts about leaving medicine may have started.

So at the very end of the week I was so stressed, I was stressed beyond–my preceptor asked me to come into this empty clinic room to do my end of the week evaluation. And I know that she's going to say really terrible things. She starts out saying, “Oh, you're well below the level of what I would expect you to be at this stage.” Then she specifically says, “I did that by design. I wanted you to be in the emergency room doing all the admissions, by design.” And in my head, I'm thinking, “How do you think that third-year med student would be able to handle that alone and not be overwhelmed or stumble in some way?” And that has stuck in my mind that she really, she did it on purpose. And she really thought that it was a good thing. She actually believed that she was being a good and effective teacher. And I am so blown away by the disconnect. I would say at that point not knowing was not an option.

I didn't know how to take a stab at it. Making mistakes was not framed as something to learn and grow from. It was really hard for me to climb out of that. And that definitely had an impact–I think the start of feeling like a stranger or an outsider in medicine. And I certainly don't think she had any clue, kind of, the repercussions or the impact it would have on me. It was one of those things where I feel like the hazing, I don't think I emerged like a phoenix out of the ashes. I feel like I just crawled out on my arms and my knees, and had to slowly rebuild myself.

Chief Resident

So a little over a year ago, I had to remediate an intern. I was chief resident at the time, and it had come to our attention that this particular intern just wasn't cutting it in terms of their performance, and there were serious concerns about whether they were going to be able to move forward. I don't know if you've ever had to remediate an intern before. But there is lots of information out there. There's plenty of details, you know, when you google it, about basically how to go about it in the right way so that you don't make any human resources violations or bring yourself, like, liable for a lawsuit. But in terms of actually how to do it, how to improve the performance of one of your trainees, there's really not a lot out there. And so I was coming into it purely blind. And this is where it comes down to shame. I've always felt that the issues that come up is that you either have too little shame or too much of it. Too little means that you're overly confident. You think you know everything and no one can tell you anything to improve upon the work that you're doing. The other side is having too much shame–being so incredibly anxious, nervous, overwhelmed by the thought of making a mistake, and convinced that your performance isn't up to par, so much that it's almost like a neuroses. It paralyzes you from being able to do the job. But this case was different. This intern, didn't really fit into what I thought I knew were the categories that can cause issues. And it's kind of made me question the whole process of our medical training in general.

It's a little hard to describe, but let me try to put it this way. Have you ever heard of a feedback sandwich? It's basically this concept that when you’re giving feedback, you give a positive comment, then a negative comment, and then you end with a positive comment. That's a broad generalization. But I've heard it commonly used as a way of trying to give feedback and ensure improvement, and part of the clinical training for interns, residents and other trainees. If you've ever been on the receiving end, and you're like me, essentially what you take away from this is that you only focus on the negative, and you kind of see through the positive compliments or positive attributes as just something that was just getting in the way. And you just harp on the negative and focus on that entirely. This intern would essentially, interestingly enough, only take the positive, but not really see the point of the negative. And so, six months into this intern’s first year of training, something had to change.

And so I changed it up. I was the most direct, extremely critical, ruthless, but fair, but still ruthless in the critiques and in the intensive training that we provided to this individual, to help them improve. And even though I knew it was the right thing, and even though I knew it got good results, because we did see improvement, it felt awful. It worked. The intern got better. They had improved performance and better evaluations. But I couldn't shake this feeling as to why it felt so terrible to be the one delivering that.

You know, as I look back on residency training, I feel like so often I would get advice from those above me, whether it be senior residents or faculty or, or other folks that I would go to for advice, and they would often tell me just to trust the process. And I, in turn, have absolutely said that exact same phrase to trainees. But it made me question, what is the process? You know, is the process, you know, going through training, having anxiety, sleepless nights, flashbacks of some of the most intense situations that I've had in terms of codes or difficult patient scenarios, all with this constant self-critique of what I had done wrong and, you know, harping on the ways that I could have done better? Just do that, also, while working harder than I ever had before? And after about three or four years of training, hey, you come out, and now you're an attending? And in some way, I felt like that's what I was passing on to this other individual that I was supposedly remediating and bringing into the fold. But as I look back on it, if that's really the process that's going on, as I reflect as a new attending into this profession, I'm not sure if I want to perpetuate it.

Cynthia Shortell

My role is, first and foremost, I'm a vascular surgeon. I've been the division chief of the division of vascular and endovascular surgery here, too, for fourteen years. And then, for the past five years, I've been the chief of staff for the department of surgery. I think it's very telling that over thirty years later, I still remember every detail as though it were yesterday–the color of the walls and the, you know, the floor and, and, and all of that. When I was an intern, I was, still am, very short, very slight. There was only one other woman in the entire surgery residency. It was just like being a round peg in a square hole. But there was a senior resident who had transferred in from another program. This individual, six-and-a-half feet tall, very strongly built, and, so, physically intimidating, in addition to that very powerful hierarchy that was, I think–still present in surgery–but was much more pronounced at that time. There were repeated episodes of, where I felt he shamed me. But the two that I remember very clearly, were: I had rounded one morning, he hadn't rounded yet. I was telling him what I had done with our patients. And I mentioned that I had taken the NG tube out of one patient, and he became irate. We were in the middle of the hallway, he started screaming at me, “Why did you do that? Was the, was the drainage bilious?” Over and over, “Was it green? Was it bile? Are you sure?” And it was humiliating for me in the middle of the hallway–all the nurses, all the residents hearing this. And all I could do was say, “No, yes, yes, it was,” of course, beginning to think, you know, “Well, was it really?” and, you know, “Obviously, I don't know what I'm doing.” And, sort of, the good part of the story is that a chief resident who was a year senior to this individual, who had worked with me earlier in the year and who believed in me, overheard this, walked down the hall and confronted this individual and said, “What are you doing? This is not how you treat people. This is not how you teach people.”

And another event with the same individual: We had a trauma patient, hypertensive with a ruptured spleen, we were trying to take from the emergency room to the operating room. And he and I were in the elevator with the patient, and the elevator went the wrong way. And I think that he thought that I'd done that, that it was, you know, my fault. I don't know, I don't know what made the elevator go the wrong way. But he was furious. And I was standing to his right, we were with the patient, we were beside the patient. And, as I mentioned, he was a very large individual, he took his fist and punched through the glass ceiling panel in the elevator and it shattered over my head. And I was terrified! In the elevator with this guy I didn’t know. You know, I felt, of course, you know, “Oh, my God, I pushed the wrong button. I'm such an idiot.” And then I just stood there, I didn't know what to do. I didn't know what to say. I just looked at the glass in my hair and, you know, I said nothing.

Those interactions with that individual, I think, really shook me up in terms of my confidence, my faith in, you know, “Did I take, do I know what I'm doing? Was it really green? Did it push the wrong button?” You know, how you doubt yourself when things go wrong. When you have those experiences, then the next time you tend to blame yourself. That's the go-to. The default is, “It's my fault. I'm bad, I'm shameful, I'm not good at what I do, I shouldn't be doing this. You should quit surgery.”

Maybe this is a bad analogy, but I think about it like military training. And as you're training to be a doctor, and, particularly in surgery, where you do have to endure very intense stresses, both in the operating room, as a leader, dealing with patients, their families when they're in dire straits, being tired. So there is that idea of, just like in the military, having to prepare people for what that's going to be about. They can't go from medical school to being responsible for people's lives without some sort of transition of understanding what that will be like. I don't think shame has to be part of it. But I think that developing the skills to endure emotional distress–that has to be part of it. Part of this is to be able to keep going when you've made a mistake. If you make a mistake in the operating room, you have to keep going. So we do need to be able to teach people how to do that. I think traditionally shaming has been one way of doing that. Certainly, you know, if someone feels shame, and they have to keep going, it's a way of learning to endure emotional distress or distress in general. And if you're tired, if you're feeling bad about something, if you had a difficult interaction with patients, family, all those things, you still have to keep going and be the best version of yourself that you can be. And I think shaming has been used to achieve that. But I think we've got to find other ways because it’s probably not the best way.

Emily Silverman

Hi, Will!

Will Bynum

Hey, Emily!

Emily Silverman

For those of you who don't remember Will, he is a family medicine physician at Duke, and residency program director. So, Will, you've been studying shame and medical learners for almost 10 years now. You've talked to, I think it's around forty people for the formal qualitative interviews, and then hundreds more informally. How is shame coming up for people at the residency and med student and pre-med student level?

Will Bynum

So when we talk to people about shame we hear about a lot of the hidden aspects of the experience of learning medicine that no one ever talks about. We hear about people, you know, struggling on a normal learning task, people being ostracized for the way that they dress or the way that they talk. We hear about people being marginalized on teams and left out of learning experiences. We hear about people being humiliated and yelled at or harshly questioned or interrogated. We hear about their expectations for themselves, a motivation to learn and be better, but that can also lead to shame in moments of failure. We also hear a lot about people who engage with shame and manage to overcome it and transition into something more constructive, and, and thus grow from it. So it's not all bad. But in order to get to the growth and engagement that can come after it, there needs to be a process of moving through it in a constructive manner. And that's the part of our research we haven't had the opportunity yet to delve into as deeply.

Emily Silverman

In Episode One, we talked a bit about chronic shame, and how if you expect to find shame, you may find it in places that other people view as, what's more of a benign or normal situation. So how do you know if you're feeling shame because you're actually being shamed? Or if you're having an outsized emotional reaction to something normal, like just being asked a question on rounds?

Will Bynum

I don't think you do know in a moment. And that's the thing about shame, is that it can distort your view of objective reality. So, irrespective of how silly or trivial the trigger may seem that induces a shame reaction in yourself, once it takes root, it doesn't matter how trivial or benign it was. It’s, it's important, it was significant. And that's where awareness of shame is really important, because an event that triggers shame in one person may be seen as a normal event, or even an opportunity to learn in another person. And that's where some of the culture of shame may have persisted in medical education, where I was taught by being shamed, and either I developed resilience to that, or I saw it as a normal part of my education. And therefore, when I'm now the teacher, I shame someone else, because that is seen as an effective pedagogy. But that other person receiving that treatment may have a completely different response than I did. And it may be incredibly shame-inducing, such that the use of shame as a teaching tactic is fraught with risk. And in many ways, it's completely unnecessary.

Emily Silverman

Most people in medicine, who I've talked to, have a memory of a time that they were asked, like, a really specific question about some medical detail, and not knowing the answer, and then they never forget the answer to that question. So one thing I'm wondering here is, is shame ever good? Is it ever an effective teaching tool?

Will Bynum

That's such a loaded question. And some of it depends on what you consider to be effective. If you consider the ability to retain information, develop memory for an event and learn from it as a result, shame can be a very effective teaching strategy. It is absolutely going to attach an emotional experience to that learning opportunity. And, in so doing, it will likely drive memory for it. But one of our participants kind of famously said, “I wish I could have learned without so much emotional baggage along the way.” There is a real cost to teaching with shame as a tool. And it's that, along the way of developing that memory, we may also be developing a lot of maladaptive behaviors, responses, motivational stances that naturally come from feeling shame. And that's especially probably true if the shame is chronic. So if we are constantly taught by being shamed, or we're constantly experiencing shame while learning, the cumulative effect of that can lead us to isolate ourselves, to withdraw, to stop taking the risks necessary in learning, to begin viewing ourselves as unworthy of being in a space, or unworthy of progressing to independent practice in medicine. And while we might be remembering things along the way, I would not say that that is constructive growth, especially when we think about what's required to be successful and effective in medicine, which is the ability to be empathic and to be vulnerable and to take risks, and maybe more importantly, to be willing to learn from our mistakes.

Emily Silverman

Can you envision a training program, either for teachers or learners or both, that helps people understand these concepts and prepares them to be a better teacher and a better learner.

Will Bynum

I mean, I think about this all the time. Like, how do we translate research about shame or awareness about it? How do you actually translate that into meaningful impact at a program level, institutional level, individual level? And I, there are a lot of ways that I think we can do that. I do think people can be, quote, unquote, trained to identify shame, to respond to a learner experiencing shame or their own shame, to create environments that are conducive to that growth and engagement. But I, sometimes I actually recoil a little bit at the notion of training because it seems to suggest that there are novices and experts and that we can all become expert if we just get trained on it. And what I might actually say is that every single one of us is an expert on this emotion because we've experienced it, almost undoubtedly. I mean, that gives you a degree of expertise in supporting someone who's going through a shame-experience, and recognizing it and creating the environmental conditions necessary to engage with it, because all you have to do is think about what you would need. So while we can definitely train people, we also just need to ask people to draw upon their own experiences as humans, and then to use that to make your education system better for everybody.

Emily Silverman

So what I'm hearing is that there's potential for change on both sides of the equation. On the side of the teacher, there's a responsibility not to be cruel, to create environments of psychological safety, to get to know your learners. And then on the side of the learner, there's an opportunity to take control over how you feel about yourself, and not let those irrational shame voices take over the conversation.

Will Bynum

If you're a teacher, you ideally should care about the people you're teaching. Right? You should care about them as people, you should care about their experience, you should be committed to their growth in their learning. And if those things are true, it naturally follows that you must care about how they feel about themselves as you teach them. A: Because you care about them, right? And we know that shame can be a very distressing emotion that can really lead to a lot of suffering. But also because shame can impede meaningful learning and growth so significantly. And so I think it's a minimum responsibility of teachers to teach in a way that at least mitigates the potential for serious shame to happen. You cannot control how someone feels about themselves in a moment, right? But you can certainly create conditions and teaching tactics that lower the risk of shame. And the way I would summarize that is just to be kind, just teach with kindness. If you teach with kindness, the chances of you inducing a shame reaction are much lower. On the part of the learner, take the power back. Even in an experience where someone is attempting to shame you or humiliate you, it is an act of agency to say, “Nope, I'm not believing that. I know that I don't deserve this treatment. Your feedback might be the problem, not me. And I'm not going to internalize what it is that you're saying to me.” I think it's harder when there's a power differential or when we are prone to shame already. But that is an act of agency. I think that it starts with education, though, if we can really address the role of shame in medical education, if we can eliminate intentional shaming and harness what remains, for good, I think it will have profound downstream effects on the practice of medicine. Because, essentially, we're building a new culture, we're building new norms. And I'm really empowered by the idea that any ideology that's been built, any culture that's been built, it can be dismantled and rebuilt in a different way. We maintain these things, and so we have the ability to change them.

Emily Silverman

Thanks for listening. Before you go, I wanted to remind you that Tuesday, October 18, The Nocturnists is proud to be co-presenting a live show with the UCSF Memory and Aging Center, Global Brain Health Institute, and the San Francisco Conservatory of Music on the topic of sleep and dreams. Tickets are sold out to attend in person, but you can still check out the show by tuning into the live stream from 6:00-7:30 pm Pacific. This will be an awesome evening with storytelling, musical performances and scientific talks, all exploring the art and science of sleep and dreams. Visit thenocturnists.com/sleep-dreams and follow the links to register. Over the next few episodes we're going to continue to explore how shame manifests in medical culture. Next week, we'll be focusing on shame and medical errors.

To contribute your reactions and reflections to our shame series, and to access additional resources like transcripts, discussion guides, and more, please visit our website at thenocturnists-shame.org.

Shame in Medicine: The Lost Forest was co-created by me, Emily Silverman, as well as Will Bynum and Luna Dolezal. Our producers are Sam Osborn and Molly Rose-Williams, with additional producing by Adelaide Papazoglou. Sam also edited and mixed the series. Thanks to medical student producers Corinne April Iolanda Conn and Nikhil Rajapuram, production coordinator Penelope Lusk, impact campaign manager and assistant producer Carly Besser, and Exeter team coordinator Alice Waterson. The Nocturnists’ executive producer is Ali Block, and our chief operating officer is Rebecca Groves. The series illustrations are by Beppe Conti, and the music comes from Blue Dot Sessions.

Shame in Medicine: The Lost Forest was made possible in part by the Shame in Medicine Project at the University of Exeter, funded by the Wellcome Trust. The Nocturnists is supported by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org. Our show is also made possible with donations from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoy the show, please follow us on your favorite podcast app so you don't miss an episode. While you're in there, you can help others find us by leaving us a rating and review. To contribute your voice to an upcoming project or to support our work with a donation, visit our website at thenocturnists.com. I'm your host, Emily Silverman.

See you next week.