We are shame-full

A couple of weeks ago I was out for one of my routine dinner dates with Gia Lewis and Tom Varghese; dinners like these are something I highly recommend as a way to stay connected to your core values with people who share them.  And, of course, we manage to resolve plenty of the world’s issues and discover that we’re all wickedly funny.  I also walk away from these dinners learning at least one new thing.

Other than encouraging you to hang out with people you adore (because we ALL need more of that!), there really is a point to the story about our recent dinner. We got into a fairly intense discussion of surgical culture and the fact that moving the needle to be more inclusive and kinder is just plain hard. Sure, there are all of those things that we learned in kindergarten (credit to Mind Shift for this great infographic).

But somehow in the moment of being an adult and trying to get ahead, we lose sight of so many of those things. Or we’re taught that they aren’t actually cultural expectations where we are, and slowly we become less connected to the value of not hitting people (perhaps not physically, but you get the idea) or telling people we are sorry. Most importantly, we transition from the idea of feeling guilty (“I did a bad thing”) to feeling shame (“I am a bad thing”). As Gia astutely stated, in surgery we are cultivators of artisan shame: “We water it, we cultivate it, we sell it at the Farmer’s Market on Saturday morning.” (See, I told you we’re funny, even when we’re speaking painful truth.) And, of course, shame is highly correlated with maladaptive behaviors and burnout.

So what is a surgeon to do to help herself and her colleagues function in a less shame-full world? Besides warm cookies and cold milk, how can we help change things? Brené Brown has some ideas, of course, since she’s made a career of researching shame- and I’ve had a couple of interesting email exchanges with her about shame and surgical culture.

Brené on surgical checklists: “When they teach those folks how to suture, they also teach them how to stitch their sense of self-worth to being all-powerful, and all-powerful folks don’t need checklists.”

Yep.  This is us.  This is who we are. And watching her TED talk again left me with so very many questions if we’re going to do this and foster a place that supports creativity and innovation…

How do we help each other be less afraid to fail?

How do we help each other to conquer impostor syndrome?

How do we help each other be “enough”?

How do we apologize to each other, to our patients, to their families when things go wrong and we make those mistakes?

How do we help our female colleagues understand that we do NOT have to do it all?

How do we help our male colleagues understand that it’s okay to be weak, it’s okay to fall down?

How do we get rid of secrecy, silence, and judgment that allow shame to flourish?

How do we help each other to show up being our best- and imperfect- selves?

Perhaps the secret starts exactly where we were on that Friday night- hanging out with people we adore.  I want to believe it’s a first step.



Shame, patients, and the Internet

“If we can share our story with someone who responds with empathy and understanding, shame can’t survive.”- Brené Brown

Last week over lunch, a colleague and I were discussing some of the on-line physician groups that are out there.  Some are on-line communities within organizations, others are Facebook groups. While we both acknowledged that some of those groups can be incredibly helpful for building a community around shared experiences in the challenges of our work, she astutely noted something troubling to her, and that I realized had been an intangible quality that had troubled me more than once.

It’s the fact that within that “safe” space there seems to be this more-than-casual practice of patient-shaming (Note: It’s the Internet, people. Nothing is “safe” if someone gets a screen shot.). It’s the discussion the obese patient, or the patient whose lifestyle choices we disagree with, or the patient who keeps turning up in our clinic with injuries from self-harming in a way that judges them.

As physicians we’re known to sometimes do this in person, and it seems to be we’re more likely to do it to women (yes, there’s both anecdote and science supporting that claim).  But the internet, particularly these spaces in which we’re with our own people, provides a whole new area of questions around how we talk about our patients.

I’ve heard the argument that it’s like being in the physician’s lounge to talk about patients in this sort of space. I would argue it’s nothing like that, mostly because we don’t have direct personal relationships with most of the individuals in those communities and you don’t know if someone caught a screen shot of something posted that crossed a line. It would be horrifying to post something, realize later it wasn’t a good idea, go back and take it down, and only have it come back to haunt you later because of the dreaded posterity of the internet.

I get that we’re tired, that many of us are struggling with burnout, and that we need some sort of way to process dealing with patients who challenge us.  I’m not saying that I haven’t (under a cone of silence in a true safe space) expressed frustration with a patient and/ or their family; if you haven’t EVER done that, you’re a better person than most of us in healthcare, and we also want to know where you acquired your collection of perfect patients. What I am saying is that we have an obligation as leaders and as human beings to think carefully about the reprecussions of things we say and things we write. More importantly, even when we’re tired and cranky and just DONE, that’s the time we need most to call on our compassion and remember why we chose this profession in the first place. And, of course, we need to choose our audience very carefully when we really just need to vent- and we need to stay out of judgment when we do.

Before you post that patient story in a community or group, think about how you would feel if you knew that you or someone dear to you were being written about in the way you intend to tell the story.  If the answer is either “not very good” or “I’d be furious”, it’s wise to reconsider your decision. And if you see or hear something that makes you uncomfortable, I would encourage you to let the author know that it does and why. We need to learn from one another, and we need to encourage one another to be our very best selves.


Shame on you. Or perhaps shame on me?

“Vulnerability is the birthplace of innovation, creativity, and change.”

I was introduced to the work of Brené Brown just before the publication of her book The Gifts of Imperfection.  If you haven’t come across her work via Oprah or another major media outlet, Brené has a PhD in social work; her area of emphasis in her work is shame.

Yes, shame.

I Thought it Was Just Me was life-changing reading for me.  It was that big. As I was reading her work on shame and the quest for perfection (and both of their complex relationships with power structures), I saw our medical education system.  I saw so much of surgical education in particular, and could attach names to the pictures of “parents” (senior residents, faculty members) who adhered to the shame and blame paradigm rather than fostering compassion and a healthy sense of guilt.  When my colleague Will Elder was conducting interviews for our work on disruptive surgeon behavior he brought back to me the use of the word “shame” by one of our interviewees, who was describing the educational philosophy ascribed to by disruptive faculty.  On that day I knew we were on to something big.  I still believe that.

Brené describes shame as “the gremlin who says, ah-ah, you’re not good enough.”  Here’s the thing about shame:  it has lots of dirty side-effects. Shame increases dysfunctional coping, be that addiction, violence, eating disorders…things that people do to maintain disconnection from the world around them.  In our profession, shame looks like burnout and impaired physicians, and the perfectionistic tendencies of almost all of us in medicine put us at higher risk than the “average” person.  Our culture and ourselves provide a set-up for us to self-destruct- and the data show that many (too many!) of us do just that.

Since my initial reading of Brené’s work, I’ve committed to trying to change my corner of the surgical world by making it a place where we strive to say, “I made a mistake and I’m going to do better” (guilt) rather than, “I am a mistake and can’t do better.” (shame)  Like any parent or any human, I’m not perfect, and some days I am very, very far from perfect in leading that culture change.  I try to provide a safe place for my trainees, particularly the students, to talk about the “hard stuff” that is inevitably part of medical education.    And, to be completely transparent, I started this blog in hopes that it could be an antidote to shame as colleagues read it and think, “Yeah.  Me too.”  The most rewarding part of my electronic relationship with you, dear reader, over the last year and a half has been how many people have told me they’ve really connected with something that I wrote here.  I have weeks that I suspect my crazy ideas here are more impactful than a great deal of my academic work.  And I believe that my vulnerability here has been the nidus for a tremendous amount of innovation, creativity, and change.

For those curious about Brené Brown’s work, this TED talk is a terrific introduction to her ideas.  And, of course, as a Texan she tells great stories.

An elephant in the corner

I was grateful for this essay published in the New York Times last week, just before National Suicide Prevention Week.   The author cites some important statistics, the most important of which is that physicians are more than twice as likely as non-physicians to commit suicide.  He also cites the suicidality data from a recent multi center study, which he mentions to the exclusion of the depression data in the same study, which showed a depression rate in trainees of over 20%, with the rate higher in medical students.  Subsequent work has shown an increased incidence of burnout among residents and fellows rather than depression, although burnout is higher in all levels of physician trainees than in population norms.

As surgeons, we tend to want to believe that we are different:  we’re somehow tougher, more immune to the qualities that make everyone else merely mortal. Perhaps that tendency itself is one of many causes behind a rate of suicidal ideation in surgeons that is nearly twice that of the general population (and the associated tendency to not seek help for burnout and depression).  We also seem to want to find a simple formula for self-care and personal wellness that can serve as a panacea for depression, burnout, and their associated consequences.  And while the truth is that self-care and wellness help, perfectionism and an easily-accessed sense of shame are drivers of many high-performers…and I will agree that surgeons are, as a group, high-performers.

If you know me well at a personal level, you know that I have been a HUGE fan of Brene Brown’s work on shame and authenticity for several years now.  Quite honestly, her work was life-changing for me because of the perspective it provided me on dysfunctional behaviors that I witness and dysfunctional behaviors I may have exhibited myself at some point.  Using that lens of shame, I was able to see how often we use it as a tool in education.  I was flabbergasted when we were doing our interviews for the disruptive surgeon study and several interviewees mentioned the tendency of disruptive surgeons to use shame as a “motivational technique.”

We have seen the enemy, and apparently it is us.

So, where do I propose that we go from here?

If you’re feeling burned out, if you’re able to recognize that you’re depressed, ask for help.  Find someone whom you trust, someone who you feel has “earned the right” to hear your story, and talk to them.  In hindsight, I’ve realized the value of a couple of my friendships during residency, both of which were sanity-savers, if not life-savers.  In particular, during my last two years of residency, my friend Katie and I would meet nightly to walk her dog on the Shoreline Trail. I probably can’t count the number of times as we talked when each of us thought “Wow!  I get that.  It’s happened to me too.”

If you see signs of depression or burnout in a colleague, offer to be that support.  Providing some empathy if they say, “I’m stuck, it’s dark, I’m overwhelmed!” might just make the difference.