[00:00:00] Christine J Ko: Welcome back to SEE HEAR FEEL. Today, I have the great pleasure of speaking with Dr. Will Edwards Bynum IV. Dr. Bynum is an MD and Associate Professor in Family Medicine and Community Health at Duke University. I previously spoke with him about shame. This is a second episode that will continue the conversation. Just a little bit more about Dr. Bynum, for those of you who were not able to tune in to the first episode. He served 7 years of active duty in the US Air Force before working at Duke. His primary academic interest is focused on the medical learning experience, and the relationship of that experience to self-conscious emotions, such as shame. In the last episode, we spoke about shame resilience in medical learners and providers. This episode, we will dive deeper into shame, the experiences that shame can be a part of, and how we might address it better in medical education.
[00:00:59] How did you come to study shame in medical education?
[00:01:03] Will Bynum: From a shame experience?
[00:01:04] Christine J Ko: Okay.
[00:01:05] Will Bynum: In residency, I made an error that hurt a patient, pretty significantly. At the same time, and I can't remember now which one came first, but very closely linked to that was getting out of a suboptimal, crappy relationship. I was never overtly mistreated in this relationship, but I probably was subversively and insidiously mistreated. Along the way, I lost a sense of self, the social, personal side. The medical side, being a trainee, I was in residency at the time - that wasn't affected too bad- but everything else was. When I got out of that relationship, it was literally like the clouds parted. Like I was wearing kaleidoscopic glasses or something and couldn't see things straight, especially my own view of the mirror, and I took those off, and it was suddenly very clear. Whoa, you've really gotten off track with how you feel about and know yourself. It was the tiniest bit of perspective, like days after. It was pretty jarring, the recovery from that, wanting to figure out what happened. I discovered Brene Brown, and credit to her, because she made shame okay, and normal, and even funny. It's her original Ted talk that I watched, and I could not believe it. I was like, Oh my God, this is exactly what I'm feeling.
[00:02:11] I was able to say, Okay, you felt bad about yourself. Let's do something about it. Now you have this construct, and here's this cool woman who's making it so accessible and real. As I went through that process of personal recovery, which is unbelievably growth inducing for me, I think I then said, Oh my God, that error that I made, that was a massive shame response that I had afterwards. It was a huge shame response. A whole new perspective on that whole experience then led to reading in psychology and the MedEd literature.
[00:02:40] Realizing that, Wow, this is an emotion that is all around me, within me, and yet, no one's talking about it and hardly anyone has written or researched about it. That was overwhelming and really exciting. We just started diving in, and eventually someone kicked me n the butt and said, You need to actually research this, and gave me some great mentorship. And here we are.
[00:02:57] Christine J Ko: Thank you for sharing that. Yes, for sure, when we have stress at work and at home, on multiple fronts, it's really hard to see straight, literally and figuratively. Through that, I've realized that emotional intelligence, being aware, having the self-awareness to, like you just said, say, Okay, I'm feeling bad, but it doesn't mean I'm bad, and why am I feeling bad? And what can I do about it? That is shame resilience, or having an adaptive response to perfectionism. That's all very helpful.
[00:03:27] Will Bynum: I found that personally, and in our research, that shame resilience, it's a little bit of a complex term because resilience, in some ways, is becoming the R word. That it's just sometimes propagated as a way that individuals are supposed to be engaging with systems that make them fail in some way, or make them burned out, or shamed. So I'm always careful with that term, but I think when I talk about shame resilience, what I mean is the ability to proactively engage with shame in a way that allows us to move through that experience, build our self concepts, recover from the distress of it, and really hopefully internalize the experience in a way that orients us towards growth, greater self love, greater connection with others. And that's hard to do. That's really hard. Any element of that is hard. All of it is really hard.
[00:04:13] I think one of the things that's most prohibitive with recovery from shame is the proactive part, because shame is such an isolating emotion that just feels so bad. And it makes you just want to fold up into yourself and stay there in the dark. It tends to passively posture us towards help, meaning that we are less likely to seek it.
[00:04:36] We're less likely to talk about our shame or even to acknowledge it. And even if someone comes to us, we might be apt to reject that support or help. So finding ways to be proactive in dealing with our shame, in confronting it, is so critical. And I'll just say most of our healthcare environments, I think, are not prepared to facilitate that proactive engagement. So even if we want to, as people, it can be very hard to do.
[00:05:00] Christine J Ko: Absolutely. That is a really nice lead in to my next question to you, which is, what can we do to prevent shame and the negative consequences of shame in medical education and in the culture of medicine?
[00:05:12] Will Bynum: Yeah. It's a great question. And it's a complicated answer, for a couple reasons. One, I think, shame is here to stay. We're never going to prevent feeling shame, nor should we, because that would mean denying it, and then we'd have all sorts of problems. Shame is a very important emotion. We need to feel it, because when we do, it appropriately signals to us that we have done something to transgress a social norm that might be negatively impacting our own bounds or societal bounds of behavior. So we have to be able to feel shame, and we cannot try to eliminate it.
[00:05:42] What our research suggests is that there are some different flavors of shame in medical education.
[00:05:48] One flavor is shame that occurs within the course of learning that I would consider to be inevitable experiences in learning, like being wrong in public, struggling on a test or on a presentation, hurting a patient, having a moment of unprofessional behavior. Because we're all human in this very complex, high stakes, messy and learning environment. We're going to screw up, and yet that can cause a lot of shame.
[00:06:11] Another flavor is the shame that comes from engaging in that learning environment but encountering experiences that are not inevitable or not inherent and are highly problematic, like being mistreated, being harshly interrogated, humiliated, being made fun of, marginalized. Microaggressions, sexism, racism: things that are unfortunately happening every day in our learning environments that should not be and are causing a ton of shame.
[00:06:35] And then there's shame related to the nature of the profession itself. It's high standards, societal expectations, all that. Rather than thinking about shame as a unipolar emotion and construct that has to be dealt with in a similar way, I think we might want to think about it in a more nuanced way. We should eliminate the shame that is unnecessary. The shame that is intentionally leveraged to reinforce hierarchy or power, to marginalize. The weaponized shame that was intentionally induced, even in the spirit of helping someone learn, because we know that shame brings with it a lot of emotional distress, disengagement isolation, and that there have to be better ways to teach than to shame someone intentionally. That shame can be eliminated.
[00:07:15] We should eliminate intentional shaming, that sort of toxic shaming that I think is deeply embedded within our culture. Then what do we do with shame that remains. Some of that shame is appropriate, and we need to feel it, and then we need to move through it. Some of the shame is inappropriate. The inappropriate shame is that which is related to normal learning. It's understandable, but it's inappropriate. We should not feel shame for struggling on a learning task, especially when we're brand new at it. One of the things I try to tell everyone is help your learners understand that they're not performing for you while they're learning. That they're rehearsing. And if we can help people really embrace the notion of rehearsal and practice, we lower the stakes. We don't attach our self worth and our identity so much to the process of learning, and we more freely engage with it.
[00:07:58] The inappropriate shame can often be levied by more realistic expectations of ourselves as learners. And environments that are ready to allow us to rehearse allow us to be imperfect and flawed. Have a bad day, or need support, have a mental health crisis, et cetera, so that we stop stigmatizing and making taboo that experience of struggling.
[00:08:18] The shame that is inevitable just happens because we're flawed humans, and we should feel shame. We need to be kinder to each other, to ourselves. If we show up late for work, if you snap at someone in the operating room, you apologize, ask for forgiveness, and then be met with grace from someone else.
[00:08:36] If we can just have more kindness in our environments and humanize each other more and care for each other more, I think a lot of the shame that maybe is culturally embedded might begin to fade away.
[00:08:46] Christine J Ko: I love that. I love everything that you said. I do that with my kids, for sure. Because I'll yell at them, sometimes inappropriately. I'll take something out on them because they're there, and they've really not done anything wrong, or maybe they did something very small wrong, but I'm already riled up about something else, and I'll overreact. And like you just said, I will feel ashamed of myself, and hopefully, sometimes I will immediately apologize and say, I'm sorry.
[00:09:13] I'm lucky my kids are still young enough. I guess they're used to me, but they'll look, they'll say, Okay. Yeah. It's fine. They know for sure that I am not perfect at all. So there's no need for me to constantly be hiding that I'm not perfect. So it's Oops, I made a mistake, and I'm sorry. And we move on. So I've learned from them, if you're lucky, right? Just as you said, the people around you will be kind to you, and accepting.
[00:09:37] Will Bynum: A story with my three year old, a week or two ago, it was a bad day. It was a hard day for all of us. Both kids, they're 2 and 3, one of those days where they were just awful. Any parent listening will know. You still love 'em more than anything you could imagine, but they're just awful, and I've been with them most of the day. And one of them did something crappy and I yelled at 'em. Just like what you're talking about. And I had pulled him aside, and you could tell his poor little mind was struggling with getting yelled at.
[00:10:00] And he said, Stop yelling at me. And it just was heartbreaking. It's just heartbreaking in a moment. This flush of shame and, Oh God, what am I doing? And I immediately changed my demeanor, and I sat him in my lap, and I said, Mason, I'm so sorry that I yelled at you. I'm really sorry. You don't deserve that. Can you forgive me? And he looked at me, and he gave me a huge hug and he said, It's okay, Daddy. He knew what I needed in that moment. He knew that I needed to be forgiven, and I felt so much better after it, lighter the whole rest of the night. He was lighter. They were better behaved. We all had a much better time together. Something had changed, and it was empathy. I think it's just empathy, and this little 3 year old knew in a moment what I needed, and he gave it to me, and then I was able to forgive myself. We just need more of that.
[00:10:44] Christine J Ko: One of the things that's really hard in medicine is that we don't want to make a mistake on a patient that really ends up having even a minor consequence or a severe consequence. So it's just hard. I was speaking to Dr. Pat Croskerry, who's an expert in medical decision making and critical thinking. When I asked him about his final thoughts, he said there was a physician recently who had made a mistake, an important enough mistake diagnostically that the physician tried to commit suicide. And Pat said we should be hard on ourselves when we make a mistake, but at the same time, we shouldn't be too hard on ourselves.
[00:11:22] It's this kind of contradiction where you shouldn't be too hard on yourself, but you should really be hard on yourself because someone's life can really be hanging in the balance with some of the decisions that doctors make.
[00:11:32] Do you have any final thoughts?
[00:11:34] Will Bynum: Yeah, just building off the couple things you just mentioned. It's true. We are in positions of huge responsibility. Some of us more than others. Some of you all more than others, and I have so much respect for those of you out in the war, in the medical world, who take literal lives in your hands, either in an ICU or an ER, or an operating room, anesthesiology suite. It's immense responsibility. So the chances that we will feel real deep emotion, distress, even suicidality in response to feeling like we have lapsed.... That responsibility is real. What I think drives it even more is the degree to which our self-concepts, our identities, how we've come to know and feel about ourselves, are linked to those outcomes.
[00:12:18] That's the part of it we don't talk enough about. It's not just the error that I made. It's the way I view myself and know and feel about myself now that I've made this error. We need to create more space and oxygen for those aspects of our experiences to breathe because they're hard to talk about. It's easier to talk about the technicalities of an error. It's so much harder to talk about the crushing shame I feel because of it. But that's the aspect that festers and that manifests itself in other ways that are often not healthy.
[00:12:49] Christine J Ko: Thank you. Thank you for the recent New England Journal of Medicine graphic art article on shame and learning, and some of the other work you've done. As I said, those links will be in the show notes.
[00:13:03] Yeah, thanks, Christine. This is really fantastic, and I feel better even just talking with you right now. It's definitely something here, so thanks.
