In health care, we are hardwired to do all we can to minimize error and avoid failure. The journey of training and practicing medicine rests on the premise of perfection. And yet, perfectionism and shame are thought to be the two sides of the same coin. As clinicians, we have the privilege of interacting with people from all sections of society during the most vulnerable times of their lives. It is worth considering why we have such a hard time being vulnerable ourselves.
One evening, at dinner, a friend who is a banker brought up the issue of medical errors. How it is unacceptable for doctors to mess up. She wanted to know why we don’t score a 100% on every single test, since we are dealing with precious human lives. The two doctors at the table, me included, burst out laughing. She smiled and asked “I am serious, did you score less when it came to the liver, or was it the kidney? Did you choose to skip learning about the uterus or was it the brain?!” We simply couldn’t respond, given the absurdity of the question. However, it did bring up some uncomfortable feelings, especially shame, when I remembered the tests I have failed.
The next day, I thought about her question more. About the expectations society sets for doctors and the ones we set for ourselves. As a physician, I do feel like I am expected to be the superhero at times, without a cape. These unrealistic expectations start to shape the way we behave at work and how we view life itself.
Failing exams made me question if I was good enough to practice Medicine. We know that not all good test takers make good clinicians. I wish I had responded to my friend by reminding her that clinicians are human beings, after all. We try our best and rely on a team and slew of experts to help us do our jobs.
To me, shame, guilt, fear and judgement feel like the four pillars that perfectionism stands on. The shame culture in medicine is woven thickly into the fabric of our profession. We are taught to associate vulnerability with weakness, instead of courage. And to never show any chinks in our armor.
Given the escalating rates of physician suicides and burnout, wellness and resilience are the new buzzwords. Wellness committees are becoming a norm in hospitals and training programs. A huge component of wellness is developing the ability to be vulnerable and courageous, which is teachable.
What Shame Research Tells Us
Brené Brown’s research on vulnerability and shame is compelling. It resonates with people globally and is highly applicable in health care. She defines vulnerability as that which involves uncertainty, risk and emotional exposure. According to her research, learning to be vulnerable and courageous are teachable skills. A skill set that needs to be learnt in Medical School or better yet, from childhood itself. Learning to clean our teeth and bodies is a no brainer. Cleaning our minds and sorting through emotions is equally important. Yet, most of us are not taught routinely how to do so.
Being courageous requires us to be vulnerable. In Medicine, each day is filled with uncertainty, risk, emotional exposure and new discoveries. The nature of our profession demands courage, confidence and vulnerability on a daily basis. And that is a beautiful thing. Shame, however is counterproductive and we need to learn more about it.
The way we handle shame impacts the way we treat each other and communicate with patients. It colors our responses to medical errors and affects the way we teach and treat our trainees. We are trained to recognize discomfort in patients. We are not trained how to recognize our own pain or name the emotions we feel. We are not trained to cope effectively with death, medical errors or malpractice suits. These very issues are what perpetuate a toxic culture leading to dropout, burnout and more. We are tested on our Intelligence Quotient. What about our Emotional Quotient?
My Personal Experience with Shame
My 31-year-old patient had a sudden and unexpected death in the Intensive Care Unit within a few days of his admission. His untimely death affected everyone involved in his care deeply. In the time that lapsed between his death and the autopsy report, I had experienced what shaming in medicine involved. Every physician has encountered a similar experience at some point in their careers. It is all too familiar and quite distasteful.
The safety checks we have today are a result of reported errors. Mistakes can lead to innovation and creativity. Health Care workers come to work wanting to do the right thing. And yet, to err is human. Penalties for errors are heavy in the field of health care. Whether it is losing your license to practice or facing a malpractice suit. Then there is our own conscience we get to face, hoping we did right by every patient every day. Maybe we can be more graceful in handling the moral injury and shaming that ensue when mistakes do happen in Medicine.
When we respect pain and allow ourselves to feel it fully, we heal faster. Learning to sort through difficult emotions helps us cope in a healthier way. Living with unacknowledged pain can make it easier to inflict misery on others or engage in self-destructive behaviors. Learning to recognize shame and dealing with it effectively will make us better clinicians and improve our existing culture in Medicine. These transformative skills are now being taught in workshops to employees in Silicon Valley increasingly.
It is time for Health Care to invest in these skills. It will positively impact the way we learn, work and teach; ultimately improving patient care. We are taught to prioritize patient care above all else. A paradigm shift to focusing on understanding our own inner workings first, will lead to the same goal. Learning to deal with shame is part of self-care in health care. And when clinicians practice self-care, patients receive exceptional care.
Sonali Mantoo, MD, is a Critical Care Physician, Simulation Educator, dancer and yoga teacher, currently on a sabbatical, caring for family, volunteering with non profits, blogging and experimenting with solo adventure travel. Twitter/IG @unicorndocs
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