[00:00:00] Christine J Ko: Welcome back to SEE HEAR FEEL. Today, I have the honor of speaking with Dr. Will Edwards Bynum IV. Dr. Will Edwards Bynum IV is an MD and an Associate Professor in Family Medicine and Community Health at Duke University. Prior to that, he served 7 years of active duty in the US Air Force. His primary academic interest is focused on how medical learners experience self-conscious emotions, which include shame, guilt, and pride. He looks at these emotions across medical training. In particular, Dr. Bynum's research on shame suggests that shame may lead to negative outcomes. Importantly, shame is exacerbated by the learning environment as well as personal characteristics like perfectionism. Dr. Bynum has been exploring shame resilience in medical learners as well as providers. A link to several of his articles on shame will be in the show notes, if you want to check those out. Welcome to Will.
[00:00:54] Will Bynum: Thank you for having me.
[00:00:55] Christine J Ko: First of all, would you be willing to share a personal anecdote or story to help listeners get to know you a little bit better?
[00:01:01] Will Bynum: You want one related to my shame or one that is shame free?
[00:01:05] Christine J Ko: Maybe both.
[00:01:05] Will Bynum: To be honest, are we ever totally detached from our shame? Probably not. But one that would be a little more light: I've got a 2 and a 3 year old, and spent the day yesterday with them after being away for a couple of days out of town. And just getting to be in their presence and see the world through their eyes. It sounds cliché, but it's so true. They just notice things that otherwise you'd never notice. So for example, acorns on the ground. So we spent half an hour picking up acorns and talking about how they turn into oak trees. To also get to think about that myself, that this incredible complexity in the world, that we so take for granted, the kids see so naturally. That we just now overlook. It's so important to pause and think about the world we live in. Kids are my life, in so many ways, outside of anything I do professionally. So that naturally comes to mind.
[00:01:58] In terms of shame, I've had so many shame experiences. I think so many of them have become more apparent to me as I've learned more about this emotion, and what it can do, and how it feels, so that I'm more aware of it. Maybe one of the more painful was when I was, a couple years ago, going to Austria. This was in 2019, so didn't know it at the time, but pretty much the last chance to travel for a few years, anywhere. My wife was pregnant. We had a 7 month old, and we get to Toronto airport, and we're walking onto the plane and my passport is expired.
[00:02:32] Christine J Ko: Oh, no.
[00:02:32] Will Bynum: It was within six months of expiring, which means you can't go to Europe. So for any listener out there who is traveling overseas, Europe, it's got to be within 6 months of expiration. I went through just a huge shame reaction to that. I had just totally let down my family, we had to cancel the whole trip, and turn around and go home; we had a cousin that was coming along to help us take care of the kid. Let down the people at the conference. And, the narrative in my own head after that was, you're just pathetic. You can't even get this together. In reality, I spent a lot of time getting the rest of my family on that trip, that I just neglected my own details. I'm just now able to talk about this. This was a really tough experience at the time and also a very educational one.
[00:03:11] Christine J Ko: Yeah. Thank you for sharing that. Before we started recording, I was talking a little bit to Will about how I'm a fan of Brené Brown, and one of the things she has been researching is shame and vulnerability. I thought I had self-reflected on it and thought about shame in my own life. But, I recently had a couple experiences, and after speaking to Dr. Luna Dolezal, who is PI of the Shame and Medicine Project and recommended Will's work to me.... I've just realized how, yeah, there's shame. All over the place, everywhere, in every single day for me. Just as you just said, it's hard to think of any story where there's no shame involved... I thought I was the only one, but I'm glad you said that.
[00:03:56] Through the course of this podcast, shame has popped its head up a couple times. In the course of my talking to people. I've realized that, oh yeah, I have way more of a shame reaction than I ever would've realized. Can you define shame for the listeners, in case they didn't hear Luna's conversation?
[00:04:18] Will Bynum: Yeah, and I just can't praise and recommend Luna enough as a person and as a researcher, and a change agent. She's phenomenal. I would recommend that everyone check out their projects; really wonderful. Shame: there's a number of different ways to define it. I'm going to define it from the perspective more of cognitive psychology. It's an emotion that occurs when an individual engages in a self-evaluation. It's typically prompted by a triggering event, and they assess themselves to be flawed, or unworthy, or deficient, in a global sense. So they place attribution, or blame, for that triggering event on something about them, the whole person, something that's difficult to change in a moment, difficult to modify. People often say I'm not _____ enough. Good enough. Talented enough. Smart enough. Worthy enough. Hardworking enough. And Brené Brown does a great job of distilling this down to the simplest self-talk of shame being, I am bad. Whereas guilt, which is a related emotion, where the blame is placed on some thing, action; circumstantial, situational. The person may say, I did a bad thing. But I am not bad. Yeah, so shame is, I couldn't agree more, it's just an incredibly prevalent emotion, I think, in our environments in particular. We are constantly striving for high standards, I think, in medicine. To arrive at shame, we evaluate ourselves in comparison to a standard; we're constantly evaluating whether we're reaching those standards, in any given moment. Our environments constantly provide us feedback and information about whether we're reaching those standards. For me, my identity and self-concept are very much wrapped up in the ideal person I'm trying to become. And so anything I do at any given moment has the potential to give me information about whether I'm reaching it or not and therefore potentially trigger shame.
[00:06:04] Christine J Ko: Thank you. That definition makes a lot of sense. I think that's why it's taken me this long to get to, Wow. Look at all the shame that I feel all the time, on a daily basis! Because I think I was using Brené Brown's definition of, I am bad. And, I would say that I thought about and was like, Oh, I'm not thinking that I'm bad, on a daily basis. But I do have high standards, I think, as all physicians do. Especially in patient care, we want to fix problems. And we want to, ideally, get every single person better right away, in one visit, in five minutes, and move on, and have time to chat with a colleague, have a sip of water, et cetera, et cetera.
[00:06:53] These standards, they're not even really standards.... This sort of idealized or perfectionistic ideal is the standard that I'm striving for. And it's unachievable, so of course I'm going to feel shame about that all the time.
[00:07:10] Will Bynum: Yeah. In a medical learner, we've found a lot of perfectionism in our studies as contributing to shame. And it makes sense from a theoretical perspective. If the ideal self against which you're comparing yourself, in a moment, that is leading to shame, is so far away; it's impossible or difficult to achieve, then the likelihood of feeling shame is going to increase. Because you're going to fail more, you're going to reach those standards less. Practically, though, there are people out there whose failures and perfectionism don't lead to shame because they don't blame it on something global about themselves. Rather, they might blame it on something specific that is an opportunity to grow or something to fix or improve for next time. In the psychology literature, we found 2 types of perfectionism, called maladaptive and adaptive.
[00:08:01] Adaptive perfectionism is when people are perfectionist, but they respond to their failures of perfection in an adaptive, constructive way that leads to growth. Whereas maladaptive is the opposite, it's less constructive, disengaged response. What our research might suggest is that shame seems to be associated with, or facilitate, a maladaptive response. Whereas guilt may facilitate a more adaptive response.
[00:08:27] And then just to take that a step further, we also find that in the setting of adaptive perfectionism, orientation towards guilt, and focus on action that can be improved, that seems to facilitate a growth mindset: whereby if you believe that I can improve at this, I can improve at anything. I might not be very good at it, but I can improve at it. Then failures become opportunities for growth. They become sign posts that I need to get better at this.
[00:08:53] And if a guilt response, predominates, instead of a destructive shame response, it facilitates the engagement to leverage that growth mindset, for good. Whereas shame seems to be more associated with a fixed mindset, either that it drives one: I'm no good, I'm unworthy. Therefore I can never be good at this. Or it follows from one, I know I can't ever be good at this procedure so that when I screw it up, it just is proof that I'm not technical enough. I'm not talented enough. The degree to which we maybe can moderate shame versus guilt in a moment might facilitate or hinder a growth mindset.
[00:09:31] Christine J Ko: I love it that you brought up the growth mindset. I was going to ask you if a growth mindset can help counteract shame or maladaptive perfectionism, and you answered it even before I had a chance. Yes, there are several cognitive psychology concepts that I have found really useful in the past, maybe 10 years. One of the things that I've been exploring to try to help myself be a better doctor, and human being, and parent, and et cetera; one of those is definitely Carol Dweck's growth mindset.
[00:10:02] I just spoke with Dr. Marie Angele Theard, who has written an article on mindset, the growth mindset in medical education. She helped me make a connection in my mind about mindset that I hadn't previously, even though I had read her article on the mindset in medicine. It relates to what you just said, where she said a fixed mindset is really what any "-ism", like racism or sexism is about. Say I've been targeted a lot by sexism. I may internalize that and have a fixed mindset about it, myself, saying, I'm no good. And I may think it's because I'm a woman. But because of that, I can't achieve X, Y, or Z, or that's why I just failed at this. Or, that's why I'm no good or whatever. Whereas a growth mindset could counteract that sexism, even if I've internalized. It's because of X, Y, or Z that maybe I failed at that. Like you said, it's an opportunity or sign post for me then to say, Okay I'm going to try again and do this differently, maybe, but I'm going to get there.
[00:11:07] Maybe you could comment on the concept of deliberate practice, Anders Ericsson's concept, because deliberate practice is about setting an achievable goal. "I'm going to become the best doctor there is!" That's maybe not really achievable in a short step, it's not measurable in the next month or year even. But I could say, I'm going to be able to predict the diagnoses of the next 5 biopsies that I do, in my differential diagnosis. That, I could measure, and say, Oh, 3 out of the 5 biopsies that I did were skin cancer, and 2 were something completely different that I didn't even think of. You have to have a way to measure whether you're reaching a goal or not. Quote unquote, "best doctor", how do you really measure that? You could say, Okay, I want to be in a magazine that ranks doctors, that might be a way to measure it. Can you comment on deliberate practice?
[00:11:57] Will Bynum: Oh, I'm going to comment on both things you said. I think they're very relevant, and I think there's real power in thinking about the emotional links with them. First, I'll just comment on deliberate practice. This is not fully analyzed data yet, but we looked at the traits, or characteristics, or environmental factors that seem to facilitate more shame resilient versus shame susceptible responses to learning in medical education. One of the big things that we found to delineate them is whether your standards or goals or ideals are more process-oriented or are they more end-state oriented?
[00:12:35] Those goals that are more end-state oriented seem to be more prevalent or associated with shame. So for example, if my goal is to be the best doctor, if it's to become the chief resident, if it's to get into a certain residency program, those are all end-state goals. They're all fairly black and white, they're objective, you either have it or you don't, you've either achieved it or you haven't. Versus more process oriented goals, such as, I want to improve my competency, over time. I want to place this central line with less support and help than I did the last time, or without complications that I've had before, or something like that. I want to learn more, I want to know more today than I did yesterday, or next month, than I did now. When the goal is more process oriented, there seems to be more resilience to shame, when a failure occurs or a struggle occurs.
[00:13:24] Deliberate practice is really based on the notion that by doing something over and over again, you can get better at it, and you will get better at it. But you don't go from zero to 60 without a bunch of practice. It requires the acceptance of the fact that I've got to work hard to learn this, and that it's going to take some failure, and it's going to take some modification and practice, over and over. And anyone in athletics or music, I was a musician growing up, will tell you, that's how you learn something new.
[00:13:55] I think in medicine, there's a desire, if not a belief, but definitely a desire among many that, I'm just going to be good at something, right? The fact is you can't be good at it right away. And it requires a lot of deliberate practice to get better at it. And linking it to growth mindset, also comes up in the conversation of grit, from Angela Duckworth. It's really grit plus deliberate practice. It's an important combination. Also, the tendency or how you will respond emotionally, as a part of that process, probably facilitates deliberate practice as well. Deliberate practice is likely going to be undermined by really intense, or deep seated, shame and probably facilitated more by shame resilience.
[00:14:35] The other point I just want to make briefly about racism and sexism. If racism is the belief or propagation of ideas, that one racial group is inferior to another, that is in and of itself shame-inducing. Because it says, because you are of a certain race, therefore you are inferior. If someone believes that, that is a shame feeling, a global inferiority. Shame is likely a very close sibling to racism or sexism. It reinforces the power differentials, the hierarchy, the oppression that is often the intent when people use racist or sexist ideology, language, policies, et cetera. I think shame is probably a powerful emotional intermediary, if not a direct influence, on the degree to which internalized racism or sexism influences someone's motivation to learn, well-being, their engagement, their self concept, or view of themselves.
[00:15:34] Christine J Ko: Absolutely. Yes. That is really helpful. Do you have any final thoughts?
[00:15:39] Will Bynum: One final thought is we just need to open up more forums for this, because it can humanize us and it can connect us. We're all feeling some degree of these feelings. Can't we just find a way to connect more about them? We need to connect more in our healthcare environments, we need to connect more in our society. We need to connect more in our relationships. And I think that's where we find maybe the greatest shame resilience.
[00:16:05] Christine J Ko: Thank you for spending the time, for sharing of yourself, and about yourself, and creating a space with me just now where we can really focus on these kind of feelings that I do think are very prevalent in my life, for sure, and in medicine.
[00:16:21] Will Bynum: Really appreciate you having me on.
[00:16:22] Christine J Ko: Thanks.
