"Should I Be Here?" Advancing Health Engagement with Shame in Educational Transition Periods

Great um thanks so much Sherry for the kind introduction um thanks to all of you for being here and making time in your your day um I had an awesome session uh last night or yesterday evening with your colleagues and um really appreciated the questions that I got I I certainly invite any and all questions um critiques thoughts uh and will certainly save time for those at the end I also just really appreciate the opportunity to be here and to share this work with you uh and and hopefully give you some new or expanded ways of thinking about how we can best support our Learners across the Continuum of their education but certainly around the the transition periods by supporting their healthy self-conscious emotions um so I'm going to use some slides to get started um I um always finally have a disclosure it took me over a decade to get one I just want to briefly mention that um you Sherry mentioned we do a little bit of Consulting work the shame lab and we've done some work for which we've been paid around helping them develop actually a medical malpractice firm up in New York develop training for their their Physician Network um and then of course I get paid for talking here and there none of that will affect what I tell you today um but I did just want to disclose it um I also want to make an a really important acknowledgement here to the artist who who produced many of most of the illustrations that I'm going to you know use in my talk Hannah is um he's just a great friend of ours at the shame lab and just such a talented woman um also someone that just gets shame she understands it and she understands how to put it into multiple Dimensions through her art uh and you'll you'll I think get a great appreciation of how talented she is as as we go through this talk um the goals for today or the objectives I'd like for you to leave here um following this exploration of Shame and transition periods with the ability to Define what this emotion is and why it can be um potent during transition periods in particular um I want you to understand some of the drivers of Shame um during transition periods and and uh how we can begin to acknowledge them more openly and then to be able to Define the framework that we use for implementing um action uh regarding shame and that we we call shame confidence and then finally and most importantly I want you to walk away with some specific strategies things you can begin doing new ways of of looking at the experience of learning medicine that hopefully will support your learners through healthy transitions um particularly emotionally so I I I'm going to start with a personal story um I always do this because um it is such a personal topic and if we can't connect with our own experiences of Shame whether in ourselves or or in the world around us I think we will continue to be very limited in our ability to talk about it so I always start with my own story um it's also a story that happened in a transition period and it's the story that led to all this work I never set out to be what someone called me the other day you know you're the shame guy in medicine um I never said I want to be a shame guy uh in any anywhere and it's because I fell kind of face first into it and this is the story of how I did that um we use the metaphor of fire a lot to to help us understand shame and work with shame and if you think about shame as a fire then this was the match strike and it occurred during a time that um provided a very important context for this story so um that context was one in which I was a early secondy year Family Medicine resident coming through a transition period out of intern year and into one with greater responsibility being looked at um to have and carry that responsibility competently but not yet having the skill set necessary to do it consistently and that's a really challenging if not Universal place for a medical learner to be at times in their education I was also working on a labor and delivery unit that was not very friendly it was not a place where vulnerability was practiced or encouraged there was a lot of posturing it was an eaty young kind of environment and it just was not frankly a very safe place to be learning um or to be practicing or to be struggling and and in the midst of this environment and this transition period I was engaging in a self-evaluation and we constantly self-evaluate all of us it's something that our big brains allow us to do and uh my self-evaluation was one of self-doubt it was one of um wondering if I had the skills to be good enough at the position wondering whether I belonged in that environment um wondering whether I needed to change things about myself to better fit in with the sort of the cultural norms of that environment which were much different than some of the other places where I worked in my my program this range from what I would consider kind of healthy humility to impostorism where I I really had all the evidence that would suggest I could be successful in this new role but I didn't believe it um and that that was just a pervasive sense of self-doubt so that was the backdrop under which uh the the match struck the boxing lit and when it lit it was the end of a 24-hour shift I was tired it was getting ready to go home and a patient came in very abruptly having a placental abruption and as you may know that that's an obstetrical emergency where the blood supply to the baby is acutely threatened and this baby was in distress uh it was actually the head was almost beginning to Crown and so someone above my pay grade made the decision to do a vacuum assisted delivery and then pull me in the room is is an opportunity to practice so vacuum is where you know attach a little vacuum suction cup to the baby's head and you actually help pull the baby out as as Mom pushes and there was a real sense of urgency to get the baby out the room was very chaotic there were lots of people uh and there I found myself at the foot of the bed delivering this baby um again without a lot of skills yet carrying a lot of responsibility and the um the I delivered the baby successfully which was the Saving Grace of the story honestly um I I don't really don't know what would have happened had the baby been harmed but unfortunately in the process I caused a really really severe maternal injury and it was a laceration that was far more complex and um problematic than what you would expect with an assisted delivery like this it was one of those experiences where you know immediately I mean immediately you know something just went wrong and everyone around you knows something went wrong and if I put myself back in my shoes then I just remember kind of the hushed Silence of the room that seemed to quickly take hold and and um Feeling Just intensely exposed you know if the imagery in my mind going back there is one where there must have been like a semicircle of people around the bed it felt like the head of which is the patient who can't feel anything just got an epidural thankfully but uh I just remember seeing people's eyes and their eyes were shocked or they were disappointed or they were horrified or they were let down and I just remember the real sense of judgment that that they revealed and there was a fight ORF flight response in me there was fear and anxiety you know one of our research participants one time said It felt feels like my my guts fall out on the floor when I feel you know this emotion and that's how it felt for me and I had this just very primitive and very uncharacteristic for me um urge to just disappear to get out of the room and because the floor couldn't just swallow me up like I wanted it to I just handed the baby in the vacuum off to the obstetrician who took over and I just kind of quietly left the room and I got outside and there was just the only thing in this very disoriented dep personalized State um that I knew to do was just to get away from the room as soon and as far as possible and I found myself then on the other side of the hospital in a meditation room of all places you kind of in the corner of the room behind a chair just sitting head and hands and and this is where the emotional experience transitioned into something a lot more challenging and and difficult now if you were the outside Observer watching me go through this you would see probably some sort of an emotional reaction which I actually hid pretty well in the room you might see me leave if you would come and sat with me which only one person did after the error you would have you would have seen my distress and then you would have said oh he's fine um you know the fire went out he come came back to work the next day yes maybe a little bit reserved and quiet um but didn't seem worse for the wear and and in reality what I was experiencing internally but not able to share with anyone was you know the equivalent of a brush fire a force fire um emotionally that that experience of the figh ORF flight the what we call the affect of upwell it transitioned once um once it had the I had the more cognitive resources available to start thinking about what that experience meant for me it then ushered in questions like um well not even questions they weren't questions anymore they were statements it wasn't are you good enough it's it was you aren't good enough it wasn't do you belong here it was that you don't belong here you're not trustworthy you hurt people you're a bad doctor um you don't deserve the responsibilities given to you uh and it was like this just cascading Relentless internal selft talk about my Global Badness for hurting someone and it and it really kind of erased you know months or a year plus of of building credibility in my program in my mind it was just all gone in an instant so this was a really distressing experience and and it really caught me off guard um it threw me way off for days I mean I managed to get through the work days you know barely and then it just kept pervading over and over and um you know eventually I realized I got to do something about this and I reached out to my best friend in the program still my best friend today he's still in the military and um and we went out to brunch and um and I sat down I was like I got to tell you about what happened to me and what I did uh and I want to know your thoughts and it was so confusing to try to tell them what actually happened with the lastation that we're sitting at brunch in DC and uh busy Brunch Cafe or something and I had to get a napkin and fashion a vagina out of the napkin and take like a dinner roll and deliver the roll through the napkin like a baby's head to show him exactly what happened because it was so bizarre of a outcome and and I remember in that moment just the act of telling him about it was so uh was so such a relief but then laughing a little bit about it the absurdity of that situation um and then and then most critically having him listen intently listen not try to make me feel better but just listen validate what I was going through and then say I know this was terrible but I don't think this is about you I think this is about something you did and I think that could have happened to me and I think it could have happened to anybody and you know he began to kind of list off all the things that may have contributed to that that were outside of me and something wrong with me internally and globally and for the first time even though I'd had a couple of those thoughts before I was able to believe it and that was unbelievably transformational in that experience it didn't dissolve all the negative emotion about hurting someone but it oriented me more towards things that I could actually begin working on and trying to fix and not just my own sort of obsessive thinking about my own Badness and and that began my recovery along the way I did some soul searching got out of a kind of a crappy relationship where I had some feelings of inadequacy did even more soul searching and eventually came across you know the concept of Shame introduced first through Berne Brown and one of her TED talks and it was like this huge curtain went up I put on a pair of glasses and I could just see my own experiences with so much more clarity um and with those same glasses I began looking at the world around me um the you the learning environments the patient care and clinical experiences I was having watching how people interacted and I started to see shame all around me um I also went into the medical literature where I was beginning to sort of develop some academic interests found a lot of information about shame and psychology and I found a lot of signal for shame in the medad literature but hardly any explicit acknowledgement of the emotion and very very little direct research um attending to it and what that led me to realize and has continued to um you know convince me is that as I looked around in both these places for this and didn't find it yet felt it and um um you know saw it and could sense it but no one was talking about it was the notion of what I call the present absence of shame in in medicine and medical education it's an emotion that is present we feel it um and I'm going to tell you in a little bit why we feel it it's having an effect um it's it's influencing our experiences deeply significantly uh but we don't talk about it we don't acknowledge it we don't share it we don't research it so there's an absence of a attention and and um conversation and forums to begin addressing its presence and then importantly to begin working with its presence in in constructive and healthy ways which is what we're all about in the work we did um ultimately this realization led to through the help of some fantastic mentors and amazing opportunities both inside and outside of the military a dissertation that um examined qualitatively how medical learners experience shame across the Continuum of of medical education so three studies four papers and a collection of other papers um I'm actually going to share the link to this uh and I'm sharing a link to the dissertation solely because I reference it um later in the talk because it's just too hard to reference all the individual papers also if you just have someone you want to torture and want to send that link to um to read to read they can they can take a crack out it it's pretty dense but this was a really important project to go through to to develop deeper understandings of this emotion and the ways it's manifesting in medical Learners so as we did this research and as I talk about this I am always sort of careful to provide a definition of shame that gets us on the same page about what we're talking about and it's not that this is the only way to understand shame in fact I'm going to present a broader conceptualization in a minute but I want to make sure that you know what I'm talking about when I'm talking about shame and then reflect on how it Al with your understandings so as shame is largely defined in Psychology and this is a bit of an Amalgamated definition at its core it's a a negative self-conscious emotion so an emotion that occurs when we self-evaluate in which we deem ourselves to be globally flawed or deficient or unworthy in some way it's often precipitated by a triggering event but not always it can be a more chronic sort of disposition that we have rather than kind of an acute emotional event that occurs that global sense of inadequacy of negative self-evaluation is the Hallmark of Shame so when we feel shame we say things like I am bad um I am flawed I'm incompetent the other major component I want to highlight about shame is that that it it someone argue always um has an element of feeling negative judgment and that's negative judgment from other people and those people could be real the people surrounding me around the patient's bed or they could be projections of Her Imagination people that we imagine are watching us and looking at us and then we apply judgments through those imagined eyes and I certainly have done that too I do it actually all the time now if I'm having a tough moment with my kids and I'm losing you know I'm having a certain tone of voice or kind of getting frustrated I find myself wondering what someone looking out the window next door would be thinking about me as I'm doing that there's nobody there but I am projecting them in my imagination and then evaluating myself through their eyes that negative judgment particularly around something Global of the self is the Hallmark of Shame now shame is also a broad construct and I through the work I'm doing with Luna do all my colleague I'll introduce in a few minutes um Luna's helped me understand the value of not being too narrow in our conceptualizations of shame because shame does encompass a number of different effective experiences and so we we also work with this concept of the shame umbrella and it and it captures um experiences that sometimes are easier to talk about or recognize such as being humiliated or disrespected ridiculed put down vest um slandered Etc what each of these has in common is is the the perception of negative judgment and typically about something about us the whole person um as well as some of their effects of of putting us into a lower position of power of you know of self Etc so um I hope this gives some understanding of what we're talking about with shame while at the same time not being too narrow with the way we're defining it the last thing I'll tell you about some just the nuts and bolts of shame that I think is really critical when we think about how this applies to the work we do in complex organization is to talk about its distributed nature and this is something Luna and I have been working with and and grappling with and trying to make impact with this emotion within an organizational setting so shame is a uniquely individual emotion it occurs within us as we self-evaluate and only we can deem ourselves to be flawed or deficient or unworthy I mean that can be influenced by the environment around us but only we can feel the way we feel about ourselves so it is a uniquely individual emotion and it's idiosyncratic in its individuality no two people are going to experience shame the same way but while shame does have a major individual and cognitive dimension to it it also has a very potent and important relational Dimension shame comes about through our interactions with others it is something that helps govern our our social behaviors with other people it's often the avoidance of shame that drives our behaviors not just the shame itself shame can circulate among people it can circulate on a team it can circulate often down a hierarchy or down or across power differentials so it it has a very important relational component to it um and some would argue it is always a relational emotion because of that imagined or real other person and their judgment but shame also has something you know even more sort of um uh broad than that which is its institutional Dimension it can become embedded in our policies and our practices the ways in which we lay out our spaces the cultural norms that we establish um and it's not just that shame is embedded but it's the tendency to cause shame that can be embedded in these um policies and practices and material conditions so for example the morbidity IM mortality conference is a tried andrue practice of the medical education profession that can cause significant shame depending on how it's executed remediation practices hiring policies um State Medical Board proceedings all of those have the potential to have shame embedded in many Cas cases they do and then finally and sort of most broadly shame is a societal emotion it has a very powerful societal dimension mention shame shows up in marginalization in oppression in power in conflict in war it's often Luna describes it as the affective arm of those broader societal forces it's what makes people feel unworthy or not good enough or powerless because of a mechanism like marginalization or racism or oppression so shame is deeply embedded in our social structures and it can be embedded in our ideology so much so that we don't even realize it existence so this is overwhelming and it's entirely overwhelming when we work with shame because if we're going to really make change with this emotion in constructive ways we have to attend to its Dimensions at multiple levels which means that we have to work with it at multiple levels and I'll tell you in a little bit how we're doing that okay I'll bring you to the Fifth Dimension in just a few minutes there's one other to tell you about another metaphor I want to introduced because I can't help myself and uh think and dream and talking metaphors is one that is overused but is so apropo here and it's the the metaphor of an iceberg um our understanding and our conceptualizations and our conversations around well-being and the lack thereof and Healthcare are deeply anchored in experiences that we can measure you know principle which is burnout and those that we can more easily talk about um either because they've been things we talked about because they've been described well because they're not stigmatized Etc and that's led to you know conversations for example around transition periods that are largely weighted in the stress that they can cause the burnout that can be associated with it even the suicidality which we can more easily identify is tragic and as awful as it is what we what our what our conceptualizations are lacking profoundly is understanding of awareness of and conversation about the experiences like shame that are not so easily talked about that are stigmatized that are taboo that are really really personal for which we don't have easy tools to measure it and we don't have um entire conferences about its existence these experiences are critically important yet in line with that present absence concept are are not attended to to the degree we need to make the type of progress we want on challenging issues like supporting the well-being of trainees during transition periods this Iceberg metaphor I think also works and applies when we think about what we're observing in medical Learners right so above the water above the surface we see things like how they're performing we see things like their competency development their professionalism what they're wearing how they're talking how they're interacting with patients and one another we might see some signs of outward distress that we can identify we might give them a scale that can tell us how they're doing doing or feeling um for things that we can measure what we don't often see is the the self- evaluative or self-conscious processes going on underneath the surface that for reasons I'll explain don't often come up and some of those reasons are understandable and and um you know reasonable when we've looked at shame um and the nature of Shame experiences in medical Learners transition periods come up over and over again and we think it's because there are certain elements of the shame experience that drive it that exacerbate it that prolong it that are particularly Salient during transition periods and that we've observed as being present in transition periods and so some of these beneath the service processes include the the the struggle with going from objective to subjective standards this is particularly you know um relevant in the transition from preclinical to clinical learning in med school and then from you know med school to residency where we had a participant say about being in a clinical environment where he was being constantly evaluated and given subjective feedback he said God it's so hard it feels like I'm just being measured more and more with less and less of a measuring stick so the absence of scores of the um of relative performance to others of class ranks of board exams Etc which provide discreet markers of how I'm doing now those are gone and I'm Reliant now on information that's a lot Messier it's a lot more subjective it might not be delivered very effectively and I'm left trying to figure out not only how I'm doing but how to feel about myself as I'm doing it right and so what we find is that in the midst of that subjectivity particularly if the information isn't presented very effectively or is you know um negatively presented in ter terms of mistreatment that self-worth can take a a real hit ESP especially if that selfworth has become attached to performance over time and and that is something that we found widely across our data set was what psychology describes as performance-based self-esteem or that's the feeling of being worthy because I'm performing at a high level and so worth and performance become linked which is somewhat understandable you know we all probably have a degree of that but over the course of Education with continued high performance objectively in particular comes continued selfworth and and then that relationship is carried into clinical learning environments into residency where struggle is inevitable low performance is inevitable and even in the midst of decent performance the subjectivity around the the communication of that performance is um so challenging that selfworth then takes a hit and and another way to to state this is that in order to continue maintaining self worth I have to continue performing at a very high level which is impossible in the course of medical learning if we're doing it right so this this objective to subjective transition and its effects on self-evaluation are so important in understanding what's going on under the surface as Learners transition from one phase to another in clinical training another is the fact that identity is constantly and majorly shifting at times across these transitions I think this is probably the most sign it from medical school to residency um I was a program director for many years so I saw this firsthand and the the the shift of going from who I was back here to trying to figure out who am I now in this new environment with these new sets of um challenges can be really abrupt and it can be especially abrupt for people who aren't represented in that environment um and who then have to find belonging that other people are afforded much more easily but I really want to also highlight here this is one of the most important I think takeaways if you're going to take something away from this talk is that we need to expand our the conversation around identity to include self-esteem and self-worth the there's an umbrella concept for both of these from psychology called self-concept and self-concept comprises identity plus self-esteem so it's who am I and then how do I feel about who I am who am I becoming professional identity formation and then self-concept formation would say who am I becoming and how do I feel about who I'm becoming and what governs how I feel about myself what governs from where I derive my selfworth this is a a question that we do not attend to very much in medical education and I'm going to argue that it's critically important because those sources of self-esteem are constantly being negotiated and that negotiation is constantly under duress many people come into medicine with feeling good about themselves because of relationship because of hobbies because of service because of spirituality and the necessities of learning medicine often Force us to pair those down to put them to the side to make room for the the the increasing amount of self-worth that we derive from how we're doing as a learner how we're doing as a clinician um a practicing physician down the road that imbalance can be especially challenging when we're struggling at being a medical learner struggling at being a physician and the sources of self-worth we used to draw on to feel worthy are either no longer accessible they're not prominent they haven't been maintained and and now we have a precariousness in terms of how we feel about ourselves as we form this identity so I think a huge part of the work of of of this concept is figuring out how do we support the broad-based self-esteem of our medical Learners and understanding how our systems make that really difficult and I'll give you some things to think about at the end a part of the under the service milu is also the intense pressure to perform and the pressure to prove myself of wor as worthy of being at the place I'm in now of being in this your residency program of being a you know in the surgical field of being in this medical school to begin with that I have to prove myself to you while I perform as I'm learning and then finally kind of linked to that is just the intense impostor syndrome that can exist and often does exist beneath the surface especially in those early parts of a transition where I'm given responsibility I'm looked to for answers and I don't have or perceive that I have the skill set to do it confidently yet and then I can blame that on some system that let me in that it shouldn't have some set of circumstances um that got me where I am and not the achievement that I've um garnered along the way this millu is something we've got to begin talking about understanding and operationalizing in order to provide the level of support during transitions that our Learners most need and that's because these things influence how they feel about themselves how they see themselves and that influences how they show up how they engage their well-being their learning their relationships both constructively and less constructively and and I'll talk a little bit about the more constructive elements in a minute it's not surprising that we don't talk about these things it's not surprising that they remain beneath the surface and it's because I think those conver ations either don't happen can't happen or start to happen and they get sort of dulled out by the culture by the busyness by the demands of the world around us in medicine I think there are some key features of our culture in our research would would point to these that stimy that conversation or stifle it one is that we tend to see vulnerability as weakness or um stoicism as strength and that is that is a real cultural phenomenon that inhibits progress in this area reputation is so important um and I'm not saying it's not it is important I think it has incredibly outsized importance especially when you talk to the everyday medical learner who's so scared of loss of face loss of reputation being judged when they struggle Etc I mean over and over and over reputation comes up as a Salient um consideration and judgment is feared you know we're a pretty judgy group of folks I mean we need to be honest about that and if we think we aren't then just open your ears to the ways that people talk about people's making mistakes or people struggling you know how the water cooler gossip happens I mean there's a lot of judgment that happens I think we fear judgment far greater than it actually happens but we live in a Culture of Fear around being judged the cool thing about that is that we can change that like that is something we can change some of these other things are hard can't change the system in many ways but we can change whether or not we judge or feel judged and then finally one and what shame is just frankly Taboo it's just an icky concept it's not very fun to talk about or think about or admit or open um discuss so these are headwinds but the great thing about all these headwinds is that they can be addressed and changed and and one of the big key steps to changing them is just to start talking about this emotion as a normal emotion if we don't it's going to remain hidden right we naturally want to hide our shame it makes us feel imperfect and vulnerable it can make us feel shame for feeling shame and so the natural tendency is to try to to to to hide it this is especially motivated or relevant within public settings where we need to hide it from the people around us who might be judging us medicine is such a public learning uh Endeavor uh and then when we do perceive their judgment is even more more sort of motivating to to hide the things about which we're insecure or or the things about ourselves that we we deem as unworthy in the act of hiding that we often engage in behaviors that bypass shame and so there's a body of work from Donald Nathanson who's described the shame Compass which is sets of behaviors that help us move around shame rather than through it so it's a way of distracting from shame or avoiding it or repressing it through other behaviors um and we have a great example of that from our research of a learner who went through a very painful shame experience when he wasn't elected chief resident he had piled just massive amounts of selfworth on that the validation that that would provide um he had limited self-worth from other sources and and so much came from how he was perceived by his peers and being seen as smart and being seen as trustworthy and then they didn't elect him Chief and it led to a massive shame reaction in the midst of that shame reaction he remembered feeling he said uh quote I was a slave to my more primitive impulses and he said I just wanted to make someone else feel bad so that I could feel better and in the middle of that sort of emotional state he cussed out an emergency medicine attending who gave him some constructive feedback and he did it publicly and he went through a major remediation process that he he reflected he said um the program descended upon me rapidly later that day which is the program director I can relate to and that process induced his shame or exacerbated prolonged it significantly and it's because that process did not realize or acknowledge that there was shame behind the wall what that environment was seeing what the people around him were encountering were actions were projections of shame that were meant to hide it and and work around it even to himself I mean it took in this interview half the interview even to get him to begin acknowledging that there there was shame there at all and that's because it was he was trying to keep it hidden and even of consciously hidden and instead acting in ways that garnered really challenging responses reactive responses punitive responses that only deepen to shame so the concept here is that before we react to these challenging behaviors that may induce very difficult emotional reactions in us we've got to be able to pause and think about what could be going on not only emotionally in this learner but at the self-conscious emotion level so we this is a drawing that I made and just an early analysis and we we sent it off to academic medicine with the paper and they said this is great um it's good good concept can you pay a professional please to um illustrate this so this is what we came up with and I think it really is an important Mantra to consider as we work with challenging behaviors especially on professional behaviors um and finally we've come to Hannah mum who's really put the icing on the K here with her rendition um this is really really important and I think many of these behaviors we are likely to see during transition periods as people struggle we need to be able to recognize them as indicative of the possibility of underlying shame certainly not the inevitability but the possibility The Fifth Dimension I want to tell you about as I pivot to the last you know portion of this talk which is what do we do about this um is the The evolutionary dimension of shame and this has been such a godsend coming to understand the evolutionary dimension for me as a shame guy because it it's hopeful it's a hopeful Dimension it's also a very normalizing Dimension what the evolutionary Dimension says and primarily from evolutionary biology is that we are stuck with shame for a reason it's here in our human capacities because it's really helped us along the way as a human species when we were out on the tundra alone you know the middle of the food chain the thing that kept us alive was cooperation Community collaboration the thing that kept our genes going to the next um you know generation was the ability to stay in relationship with people shame became one of the most powerful markers or signals that I was about to transgress that group's Norm or it could become the mechanism through which I was ostracized outside of that group and then hopefully reformed my behavior and came back in still serves very important roles in our society in fact I would argue that we have far too little shame in certain you know actually major segments of our society right now that are presenting major problems we need to be able to feel this and we need to be able to regulate our social behaviors in so far as we do that shame is a normal human emotion and this is so powerful because so often we want to just dispatch with it we want to not feel it we want to just be shame free shame free is bad bad we don't want to be shame free we want to be shame engaged shame aware um you know and we want to avoid inducing it so because shame is a human emotion when we feel it it at a fundamental logical level simply just means that we're human and we're not broken and we're not unworthy but we have to do something with it and do something about it and in so doing shame can become a really constructive emotion and we have data this is Amalgamated data from across our studies not even an extensive list where we found important healthy outcomes in the processing of Shame now these were not passively achieved it was through processing it was through active work um that these these occurrences happened and and what we really shifting our attention to now and a lot of the work we're doing is how do we leverage shame so how do we leverage the shame that we're never going to get rid of while eliminating or mitigating the shame that isn't necessary in our environments and I think this is the ultimate question that all this poses to us if if we're going to do something about this which now that we know about it we have to so I'm going to try to answer that question in the last few minutes Che my time perfect um so I want to acknowledge you my colleague Luna here uh just very intentionally Luna is an academic philosopher at exiter she's an amazing academic partner in this work and just person she has expanded my thinking so much um and Luna's really the one that initially termed coined the term I going to tell you about very soon after which she and I began working to to build an entire framework around it so I just had to make sure Luna is acknowledged in this work the term I want to tell you about is called Shame competence and this is governing the implementation work that we're doing with this topic shame confidence is not shame resilience it might lead to some resilience but this is not a character trait it's not something that you either have or you don't and you can't develop this is a set of skills and principles and practices that we all can learn and not only can we learn them but we can apply them throughout our institutions so what shame competence entails or gives us is the ability to be aware of shame to recognize it to avoid inducing it and to support others and ourselves and proactively engaging with it in order to leverage its pro-social potential and mitigate its destructive potential so this gives us a set of abilities and we have conceptualized different levels of Shame competence and what I'm really maybe advocating for here is just the very foundational shame competence that we can start and begin implementing that I think in and of itself can be transformative we've articulated Five Pillars of Shame competence and we do work around each one of these in terms of bringing it into an organization a group of people or an individual and I'm going to interweave these five and what I'm going to tell you next but um if you wanted to read about them explicitly we have a little article in the lanet where we outline some of this in a fairly approachable not overly wordy way that um is is a nice overview the first thing I want to tell you about or suggest to you in terms of applying shame competence to support you know Learners through their transition periods in a healthy self-conscious way okay that's what this is these suggestions are about is first to recognize that period as high risk for Shame by virtue of the nature of that period the uncertainties the high stakes the new environments um the lack of intrinsic belonging and some of the characteristics of medical Learners them and ourselves right our perfectionist Tendencies our tendency to compare to others our mindsets and their tendency to be fixed Etc okay so this is just a high-risk period for shame doesn't mean that everyone's going to feel it or it's inevitable but it's likely to occur and if we can begin to conceptualize it that way it means we need to begin recognizing shame and and doing something about it as a part of this acknowledgement we also have to acknowledge the flip side of that which is what do people need to be emotionally healthy especially at a self-conscious level to feel worthy they need to feel valued and they need to feel nurtured and they need to feel cared for and these are fundamental human needs that yes medical folks need too just because we can hold ourselves to higher standards just because we can teach ourselves some emotional distance that's necessary doesn't mean that we don't have these needs and therefore it means that our environments have to meet them I don't think every medical learning environment is one that makes people feel nurtured cared for and valued and in fact I might argue that it's a minority of them that do this diffusely I think this is a huge charge and challenge to us and as folks who govern these environments um in operationalizing shame awareness it's it's looking out at people at your environments your programs and thinking as they go through these experiences how might they be feeling about themselves you know not just how are they feeling right how are they feeling is is the more kind of superficial question it's a lot easier to answer um right I'm feeling frustrated or sad or happy or burned out but how are you feeling about yourself as you go through this and that's an important question to ask is a part of Shame awareness if someone's struggling it's a totally okay question to say can you tell me how you're feeling about yourself in the midst of this struggle not just how are you feeling take it to the the self-conscious level and and in the right level of trust psychological safety um you'll be amazed at how ready people are to answer that question for you we need to begin recognizing shame um this is a whole talk for another day but there are ways that we can recognize it it has a phenomenological profile that that makes it you know recognizable in the way that people talk and carry themselves their action Tendencies um you already saw some of the behaviors that can suggest the presence of Shame shame we have to be able to look for those and then when we see them consider the possibility that shame is present okay so essentially we're asking for the adoption of a shame lens it doesn't mean that that lens is 100% always going to tell you that shame is there nor should you ever assume an act upon its um assumed presence but can we begin potentially identifying it and then opening the door for it to be expressed and shared and then engaged with and I think that's our next challenge we need to his third the third pillar we got to eliminate intentional shaming from our culture this is a long Workshop I I do another day about shaming it's the the act of causing shame in another unfortunately intentional shaming has been used as pedagogy for many many many years in medical education and it's still used today often with seemingly good results the challenge is that we don't see the emotional impact that it has because the shame part of it is hidden we we ly and I we consider shame to or shaming to be Mercurial it's like you're acting with an working with an unstable element you don't know how the person's going to respond to that shaming behavior and even when it seems constructive there's a very good chance you know as one participant said wish I could have learned how to treat a pneumonia without all that emotional baggage that came with it we also need to look critically at our structures in our organizations in our programs the in our cultures the way we do things talk to one another the way we govern ourselves where shaming or the potential for shaming could be embedded within them and then once we identify them which I think is a body of work we need to then modify them to reduce their int their potential to cause shame um and I think there are some really basic ways we can do this by just paying attention to our language paying attention to the way that we frame the the things we do paying attention to how a process might be making someone feel about thems it's it's actually not that hard you just have to apply the right lens to to consider it and then we need to stop the cycle of shaming right if we see others shaming we need to call them in we need to help educate them like hey there might be a better way to do this we've got to be Advocates you know for for stopping the intentional shaming that's surround us and then if and when we accidentally shame people it's going to happen we do everything right someone still feel a shame we need to apologize and repair I think we grossly underutilize apology and medicine and medical education and it's really a way to humanize ourselves and and to build closer bonds even when we fall short of our standards last couple we've got to support broad-based healthy multifocal self-esteem in our Learners um and there are some upfi battles we're fighting particularly around the ability for people to be self-expressive in authentic ways is a white man in medicine who presents himself in accordance with his gender identity and sexual Orient ation I um I have massive emotional privilege when it comes to my ability to safely self-express um in my environments it's a huge privilege to not have to switch to not have to assimilate to not have to change myself depending on who's around or where I am that privilege is deeply inequitably afforded in our environments and it has huge impacts on people's sense of self self-worth and their tendency to feel shame we have to do a better job of letting people and then not only letting them but celebrating them as the very diverse people they are and then in supporting their continued maintenance of the sources of selfworth that make them those diverse and and dynamic people and then finally we need to begin cultivating the ability to support people through shame once we recognize its presence we need to be able to normalize learning as struggle um I I really like to help people in residents partic particularly Junior residence students a little harder later in residency to really lean into the idea of being in rehearsal and not performance because that's what they're doing you you are not performing when you're learning you're rehearsing when you're learning helping them understand their their experience as rehearsal can really free them up to be more imperfect to struggle and to learn from that struggle and and not to feel shame about it to name and validate their emotions misss you know I I can tell you're really beating yourself up here it's an understandable way to feel right I've felt that a lot of people felt that actually has a name it's called a shame response and it's a really normal human emotion and I know it's hard and then to orient them away from damaging self assessment to something specific that they can change so I want you to stop beating yourself up for a minute leave yourself out of this what did you do that needs to be improved what did you do that led to this outcome and how are we going to begin fixing what you did or what you thought right or what happened um sometimes it's just a circumstance that has nothing to do with a person right this was just a really challenging vacuum delivery in a baby who was dying in a parum you couldn't see because there was blood everywhere it's not because you were a bad doctor because it was a hard situation we need to highlight incremental growth over time we're working with a generation of Learners of which I am a part that wants to be good right away we don't want to be inom and we don't want to be incompetent for long and medical learning just doesn't work that way help them see the growth over time especially amidst the failure that can be some of the strongest Catal of that growth sharing your own experiences can be so transformational especially if you're looked to as a mentor or someone towards which people are striving to be um to to say hey I've been through this before and it was really hard on me um can I tell you how I went through it you know can be so humanizing and then finally partnering partnering and offering con assistant sustained support in my shame experience I needed support for days to weeks it was not a one anddone thing um that active partnering of sharing our own experiences of normalizing the emotion of making it okay and then opening the door to talk about it not only Des stigmatizes it but it it it allows us to begin engaging with it in proactive constructive Community Building um and connection building ways and I think that's our ultimate charge so with that um I'll thank you for your time and attention and and be glad to take some questions well thank you so much Dr bam that was fabulous great intro to shame and some um recognition of it and how we might address it in a constructive manner um what kind of questions or comments do you have for Dr bham anybody um we had some great questions last night we have a few minutes left um one question just came through about going back to the previous slide yeah yeah yeah this is a I mean I've done entire workshops on this set of this one slide so I know it's kind of a fast and furious thing um but yeah there's a lot here wonderful thank you for moving on back others questions comments we've got some comments about how what a great session Oh Shannon I see your hand yeah hey um I'm a DUI oncologist so I did OB for my first four years so I hear you um and I know what you're talking about and it I think it might get worse in do anology um how do you you made kind of a comment about it being harder to um reach those uh our Learners the higher they get up in their training um and I find that that's really challenging in a surgical subsp specialy given that you know we as J and oncologists are kind of the primary surgeons not only but we they spend a lot of time with us and you know by the time they're in their fourth year they're feeling like they're ready they're already doing it and they still kind of have a lot left to learn and I feel like there's probably a lot of this negative processing because they want to do well for us I don't know I just do you have any tips for kind of reaching those more like Advanced timeline Learners um yeah because yeah yeah no I mean it's a great question um I think you know one of the the facets of that experience that might be relevant and important here is that what is what is often perceived or received as someone who appears really confident uh and and like they don't necessarily need more um advice or training or need to think about new ways to do things is that that is probably a quite curated and cultivated confidence that may not reflect what they internally actually feel which is insecurity and and uh doubts and and there's this kind of um I hear this all the time from Learners they'll say things like I'm supposed to be I'm not supposed to have to ask for help at this point in my training and that suggests that not supposed to suggest that there's some sort of Unwritten rule or standard that I'm supposed to be a certain way and you know shame comes from the failure to reach those standards even if it's like a totally normal standard to fail at right is a fourth year you know learner surgeon even as an early career surgeon like you're still going to make mistakes is a senior surgeon because the work we do is so imperfect and so uncertain that um that that Discord and the tension between my impression management and what I'm actually feeling can really be a hard bridge to cross you know if if it's only me trying to cross it so all that to say if if you can find ways to make it safe for them to express what they're actually doubting about themselves and and I'll tell you the ways to do that the biggest way is to say um when I was in your shoes I had tons of doubt I you know I projected confidence because I think I needed to my patients needed me to but in reality I was really I really had doubts about myself and whether I was going to be good enough at this you know and I don't think we talk enough about that is that something that you ever go through um or just to say sometimes what I do is like just present some of these ideas like yeah this is what Shane is is I always I do a um poll everywhere and I say has anybody ever felt shame as a medical trainee and I've never had a group answer less than 90% And that single fact is so important because it suddenly says Oh wait we're all feeling this right so then it's like well then let's talk about it so you have to find inroads to get to make it okay for this experience to happen even just to normalize it and then people will start expressing these experiences and then you can talk about what that tension is actually like so I mean there's there's other ways I could answer this I think the most important is just to normalize the experience as opposed to saying this isn't something you should be feeling thank you that's very helpful awesome it looks like uh Dr yuck has a question she's been her hand raised thank you Dr hello I'm Lisa thank you for that um I really appreciate it I was thinking in particular about the shame that happens around remediation for our training and how um whenever we have people who have succeeded a lot in their life and then all of a sudden are not succeeding it can feel particularly shameful and wondered if you had any ideas on how to you know address that and support them yeah oh man it's one of the biggest shame triggers that we've come across um and then as a program director I've I've just sat in just the shame soup with Learners who I've had to remediate um and some some really painful remediations um the answer is there are specific things you can do within that exact interaction and I think even more importantly there's things you can do within your program culture what we did in Du Family Medicine is from day one of intern orientation we we presented our what we call Performance Improvement processes you know we said they are remediation but really what they're for the vast majority of people they're meant to make you better right a very small subset or it's meant to be Regulatory and get you out of the profession if we're being honest but the majority of the time it really is to help you improve and so we would say any if you if you're find yourself on this pathway please know and trust that we are all doing it and working our tailes off to help you improve and get better now the degree to which they believe that is a little bit out of your control but but to plant that seed early and say ending up on this pathway does not mean you're broken or unworthy that we think you suck it means that we are investing in you to get better and there are skills that you need to improve and that the need to improve is a very normal part of learning okay so so you have to set a tone with it and then all of your all the language and wording around these processes need to align with that so when we talk about it in our clinical competency committee when we write the reports that go to gme Etc we make sure there's not shaming language in there we make sure everything aligns with performance Improvement we care about you we're here to support you and then within the interaction it's a lot of it is just going back to what do you need to get better at here are the things that you're deficient in you are not deficient yourself you aren't the problem it's the things you're doing that is the problem right and that's especially important when it's unprofessional behaviors or bad behaviors it's not to say you're a bad kid it's just to say you keep doing all these bad things you know I mean no one wants to be the bad kid in residency it's a stigmatized experience and so you have to get out ahead of that in front of that and sometimes it's just explicit acknowledgement I don't see you as an unprofessional person but damn this thing you're doing has got to stop right other people are going to start seeing you that way if you don't there's a whole group of ways you can do that maybe fundamentally where all that or originates is I care about you I care about you and your experience and I want to help you get better great points thank you so much so um Dr Dev I see your hands up I just want to acknowledge the time and it's 102 anybody who has to go can go Dr Dev if you want to stay after an anybody who wants to hear this question or the answer can certainly stay um and for a extra minutes if you'd like to do so but feel free to leave if you need to leave uh is that okay Dr Bam are you absolutely yeah I'm sorry for longwinded but yeah great question no um thank you so much and I don't mind people are not listening no first of all I want to thank you this is a outstanding outstanding really really enjoyed your lecture thank you um I think the I think it's not just the trainees and whatever I think it's the culture that we live in unfortunately yes it's definitely important for our learning um but I think it even goes beyond our our trainees it goes even to the levels where we are right because every day you're shamed for not you're finishing this or doing that or not meeting criteria not me so a lot of it also while we're we're taking this in for our Learners I hope I think it's been really outstanding to remind ourselves that we also feel that and then because it's been ingrained to us just as you said surrounding us uh it's unfortunately we realize we're not doing it we're we're not meaning to but it comes out that way so I really think it's outstanding and I think it needs to be carried Beyond just our trainees and it need to be carried all the way through through our culture so to speak but even you know starting with you know within our realm of environments and stuff so thank you so much I love that com I'm sorry go ahead Dr I just say it's a really important point I mean that this is not an emotion that any of us can can look at from a distance um and the best way to become shame competent is to First acknowledge it in yourself think about it forgive yourself for your own sort of things you feel ashamed about and then be prepared to support other people in going through it I think the two most important groups the stakeholder groups that are going to make the biggest change here are our institutional leaders and our faculty because there's this great montra that said if you don't transform shame you will transfer it and it it is a um we do a lot of Shame transference whether we realize it or not and instead of just saying stop doing that if we could first just acknowledge that we all are prone to this emotion that it's inevitable in a lot of the work we do and then process it healthfully it'll be a lot less likely that we transfer it so it's a really important Point thank you for making it no thank you really really appreciate you're getting us through through this this this lovely lecture thank you so much thank you yeah I did want to acknowledge that just the the point um that you when you talked about shame around needing to still ask questions right and you know I shouldn't be asking questions at this point um there there's one um Department one program in particular throughout our organization I'm not going to mention them but even though I think this is a really cool thing um where they explicitly tell their faculty you should if you have any doubt you need to ask questions you need to call in reinforcements and ask because there's this is such a high acut feel this is so um the the stakes are so high at this point with this particular specialty and um and it's it's such a sensitive area that if you have any question you call in reinforcements and you should not feel bad about it at all and and they tell their faculty this like you have any doubts yeah well then if you have if you have residents that are and students that are watching your faculty do that um right they're seeing that model but really what you're overcoming or having to overcome there is the the fear of judgment if I call and ask for help that someone might think I'm less competent or not good enough or not worthy of their trust you know you're you're just making you're creating a cultural norm that overcomes that stigma of asking for help and you know it's it's amazing in doing this work because it is such a fundamental emotion how many times I come across these wildly paradoxical um realities in our culture one of them is that we feel shame for asking for help right in a helping profession that's incredibly hard that no single one of us can be good enough at that we don't ever need help it's just absolutely agree the other is that we mistreat Learners while we teach them to become doctors I mean what how paradoxical is that you know so these paradoxes are both head scratching but they're also like revealing because it says hey this is basic stuff we can begin changing you know we just need a new approach I love it awesome thank you so very much thank you all for your thought-provoking questions um and uh I know Dr vam is totally open if you want to contact him um thereafter feel free to reach out to us or to him directly um with any sort of questions and we will have everything up um thank you for putting the shame lab in the chat we will put that up on our website with with all of the other um presentation the video all that kind of stuff so thank you I hope you all have a wonderful rest of the day and please         great um thanks so much Sherry for the kind introduction um thanks to all of you for being here and making time in your your day um I had an awesome session uh last night or yesterday evening with your colleagues and um really appreciated the questions that I got I I certainly invite any and all questions um critiques thoughts uh and will certainly save time for those at the end I also just really appreciate the opportunity to be here and to share this work with you uh and and hopefully give you some new or expanded ways of thinking about how we can best support our Learners across the Continuum of their education but certainly around the the transition periods by supporting their healthy self-conscious emotions um so I'm going to use some slides to get started um I um always finally have a disclosure it took me over a decade to get one I just want to briefly mention that um you Sherry mentioned we do a little bit of Consulting work the shame lab and we've done some work for which we've been paid around helping them develop actually a medical malpractice firm up in New York develop training for their their Physician Network um and then of course I get paid for talking here and there none of that will affect what I tell you today um but I did just want to disclose it um I also want to make an a really important acknowledgement here to the artist who who produced many of most of the illustrations that I'm going to you know use in my talk Hannah is um he's just a great friend of ours at the shame lab and just such a talented woman um also someone that just gets shame she understands it and she understands how to put it into multiple Dimensions through her art uh and you'll you'll I think get a great appreciation of how talented she is as as we go through this talk um the goals for today or the objectives I'd like for you to leave here um following this exploration of Shame and transition periods with the ability to Define what this emotion is and why it can be um potent during transition periods in particular um I want you to understand some of the drivers of Shame um during transition periods and and uh how we can begin to acknowledge them more openly and then to be able to Define the framework that we use for implementing um action uh regarding shame and that we we call shame confidence and then finally and most importantly I want you to walk away with some specific strategies things you can begin doing new ways of of looking at the experience of learning medicine that hopefully will support your learners through healthy transitions um particularly emotionally so I I I'm going to start with a personal story um I always do this because um it is such a personal topic and if we can't connect with our own experiences of Shame whether in ourselves or or in the world around us I think we will continue to be very limited in our ability to talk about it so I always start with my own story um it's also a story that happened in a transition period and it's the story that led to all this work I never set out to be what someone called me the other day you know you're the shame guy in medicine um I never said I want to be a shame guy uh in any anywhere and it's because I fell kind of face first into it and this is the story of how I did that um we use the metaphor of fire a lot to to help us understand shame and work with shame and if you think about shame as a fire then this was the match strike and it occurred during a time that um provided a very important context for this story so um that context was one in which I was a early secondy year Family Medicine resident coming through a transition period out of intern year and into one with greater responsibility being looked at um to have and carry that responsibility competently but not yet having the skill set necessary to do it consistently and that's a really challenging if not Universal place for a medical learner to be at times in their education I was also working on a labor and delivery unit that was not very friendly it was not a place where vulnerability was practiced or encouraged there was a lot of posturing it was an eaty young kind of environment and it just was not frankly a very safe place to be learning um or to be practicing or to be struggling and and in the midst of this environment and this transition period I was engaging in a self-evaluation and we constantly self-evaluate all of us it's something that our big brains allow us to do and uh my self-evaluation was one of self-doubt it was one of um wondering if I had the skills to be good enough at the position wondering whether I belonged in that environment um wondering whether I needed to change things about myself to better fit in with the sort of the cultural norms of that environment which were much different than some of the other places where I worked in my my program this range from what I would consider kind of healthy humility to impostorism where I I really had all the evidence that would suggest I could be successful in this new role but I didn't believe it um and that that was just a pervasive sense of self-doubt so that was the backdrop under which uh the the match struck the boxing lit and when it lit it was the end of a 24-hour shift I was tired it was getting ready to go home and a patient came in very abruptly having a placental abruption and as you may know that that's an obstetrical emergency where the blood supply to the baby is acutely threatened and this baby was in distress uh it was actually the head was almost beginning to Crown and so someone above my pay grade made the decision to do a vacuum assisted delivery and then pull me in the room is is an opportunity to practice so vacuum is where you know attach a little vacuum suction cup to the baby's head and you actually help pull the baby out as as Mom pushes and there was a real sense of urgency to get the baby out the room was very chaotic there were lots of people uh and there I found myself at the foot of the bed delivering this baby um again without a lot of skills yet carrying a lot of responsibility and the um the I delivered the baby successfully which was the Saving Grace of the story honestly um I I don't really don't know what would have happened had the baby been harmed but unfortunately in the process I caused a really really severe maternal injury and it was a laceration that was far more complex and um problematic than what you would expect with an assisted delivery like this it was one of those experiences where you know immediately I mean immediately you know something just went wrong and everyone around you knows something went wrong and if I put myself back in my shoes then I just remember kind of the hushed Silence of the room that seemed to quickly take hold and and um Feeling Just intensely exposed you know if the imagery in my mind going back there is one where there must have been like a semicircle of people around the bed it felt like the head of which is the patient who can't feel anything just got an epidural thankfully but uh I just remember seeing people's eyes and their eyes were shocked or they were disappointed or they were horrified or they were let down and I just remember the real sense of judgment that that they revealed and there was a fight ORF flight response in me there was fear and anxiety you know one of our research participants one time said It felt feels like my my guts fall out on the floor when I feel you know this emotion and that's how it felt for me and I had this just very primitive and very uncharacteristic for me um urge to just disappear to get out of the room and because the floor couldn't just swallow me up like I wanted it to I just handed the baby in the vacuum off to the obstetrician who took over and I just kind of quietly left the room and I got outside and there was just the only thing in this very disoriented dep personalized State um that I knew to do was just to get away from the room as soon and as far as possible and I found myself then on the other side of the hospital in a meditation room of all places you kind of in the corner of the room behind a chair just sitting head and hands and and this is where the emotional experience transitioned into something a lot more challenging and and difficult now if you were the outside Observer watching me go through this you would see probably some sort of an emotional reaction which I actually hid pretty well in the room you might see me leave if you would come and sat with me which only one person did after the error you would have you would have seen my distress and then you would have said oh he's fine um you know the fire went out he come came back to work the next day yes maybe a little bit reserved and quiet um but didn't seem worse for the wear and and in reality what I was experiencing internally but not able to share with anyone was you know the equivalent of a brush fire a force fire um emotionally that that experience of the figh ORF flight the what we call the affect of upwell it transitioned once um once it had the I had the more cognitive resources available to start thinking about what that experience meant for me it then ushered in questions like um well not even questions they weren't questions anymore they were statements it wasn't are you good enough it's it was you aren't good enough it wasn't do you belong here it was that you don't belong here you're not trustworthy you hurt people you're a bad doctor um you don't deserve the responsibilities given to you uh and it was like this just cascading Relentless internal selft talk about my Global Badness for hurting someone and it and it really kind of erased you know months or a year plus of of building credibility in my program in my mind it was just all gone in an instant so this was a really distressing experience and and it really caught me off guard um it threw me way off for days I mean I managed to get through the work days you know barely and then it just kept pervading over and over and um you know eventually I realized I got to do something about this and I reached out to my best friend in the program still my best friend today he's still in the military and um and we went out to brunch and um and I sat down I was like I got to tell you about what happened to me and what I did uh and I want to know your thoughts and it was so confusing to try to tell them what actually happened with the lastation that we're sitting at brunch in DC and uh busy Brunch Cafe or something and I had to get a napkin and fashion a vagina out of the napkin and take like a dinner roll and deliver the roll through the napkin like a baby's head to show him exactly what happened because it was so bizarre of a outcome and and I remember in that moment just the act of telling him about it was so uh was so such a relief but then laughing a little bit about it the absurdity of that situation um and then and then most critically having him listen intently listen not try to make me feel better but just listen validate what I was going through and then say I know this was terrible but I don't think this is about you I think this is about something you did and I think that could have happened to me and I think it could have happened to anybody and you know he began to kind of list off all the things that may have contributed to that that were outside of me and something wrong with me internally and globally and for the first time even though I'd had a couple of those thoughts before I was able to believe it and that was unbelievably transformational in that experience it didn't dissolve all the negative emotion about hurting someone but it oriented me more towards things that I could actually begin working on and trying to fix and not just my own sort of obsessive thinking about my own Badness and and that began my recovery along the way I did some soul searching got out of a kind of a crappy relationship where I had some feelings of inadequacy did even more soul searching and eventually came across you know the concept of Shame introduced first through Berne Brown and one of her TED talks and it was like this huge curtain went up I put on a pair of glasses and I could just see my own experiences with so much more clarity um and with those same glasses I began looking at the world around me um the you the learning environments the patient care and clinical experiences I was having watching how people interacted and I started to see shame all around me um I also went into the medical literature where I was beginning to sort of develop some academic interests found a lot of information about shame and psychology and I found a lot of signal for shame in the medad literature but hardly any explicit acknowledgement of the emotion and very very little direct research um attending to it and what that led me to realize and has continued to um you know convince me is that as I looked around in both these places for this and didn't find it yet felt it and um um you know saw it and could sense it but no one was talking about it was the notion of what I call the present absence of shame in in medicine and medical education it's an emotion that is present we feel it um and I'm going to tell you in a little bit why we feel it it's having an effect um it's it's influencing our experiences deeply significantly uh but we don't talk about it we don't acknowledge it we don't share it we don't research it so there's an absence of a attention and and um conversation and forums to begin addressing its presence and then importantly to begin working with its presence in in constructive and healthy ways which is what we're all about in the work we did um ultimately this realization led to through the help of some fantastic mentors and amazing opportunities both inside and outside of the military a dissertation that um examined qualitatively how medical learners experience shame across the Continuum of of medical education so three studies four papers and a collection of other papers um I'm actually going to share the link to this uh and I'm sharing a link to the dissertation solely because I reference it um later in the talk because it's just too hard to reference all the individual papers also if you just have someone you want to torture and want to send that link to um to read to read they can they can take a crack out it it's pretty dense but this was a really important project to go through to to develop deeper understandings of this emotion and the ways it's manifesting in medical Learners so as we did this research and as I talk about this I am always sort of careful to provide a definition of shame that gets us on the same page about what we're talking about and it's not that this is the only way to understand shame in fact I'm going to present a broader conceptualization in a minute but I want to make sure that you know what I'm talking about when I'm talking about shame and then reflect on how it Al with your understandings so as shame is largely defined in Psychology and this is a bit of an Amalgamated definition at its core it's a a negative self-conscious emotion so an emotion that occurs when we self-evaluate in which we deem ourselves to be globally flawed or deficient or unworthy in some way it's often precipitated by a triggering event but not always it can be a more chronic sort of disposition that we have rather than kind of an acute emotional event that occurs that global sense of inadequacy of negative self-evaluation is the Hallmark of Shame so when we feel shame we say things like I am bad um I am flawed I'm incompetent the other major component I want to highlight about shame is that that it it someone argue always um has an element of feeling negative judgment and that's negative judgment from other people and those people could be real the people surrounding me around the patient's bed or they could be projections of Her Imagination people that we imagine are watching us and looking at us and then we apply judgments through those imagined eyes and I certainly have done that too I do it actually all the time now if I'm having a tough moment with my kids and I'm losing you know I'm having a certain tone of voice or kind of getting frustrated I find myself wondering what someone looking out the window next door would be thinking about me as I'm doing that there's nobody there but I am projecting them in my imagination and then evaluating myself through their eyes that negative judgment particularly around something Global of the self is the Hallmark of Shame now shame is also a broad construct and I through the work I'm doing with Luna do all my colleague I'll introduce in a few minutes um Luna's helped me understand the value of not being too narrow in our conceptualizations of shame because shame does encompass a number of different effective experiences and so we we also work with this concept of the shame umbrella and it and it captures um experiences that sometimes are easier to talk about or recognize such as being humiliated or disrespected ridiculed put down vest um slandered Etc what each of these has in common is is the the perception of negative judgment and typically about something about us the whole person um as well as some of their effects of of putting us into a lower position of power of you know of self Etc so um I hope this gives some understanding of what we're talking about with shame while at the same time not being too narrow with the way we're defining it the last thing I'll tell you about some just the nuts and bolts of shame that I think is really critical when we think about how this applies to the work we do in complex organization is to talk about its distributed nature and this is something Luna and I have been working with and and grappling with and trying to make impact with this emotion within an organizational setting so shame is a uniquely individual emotion it occurs within us as we self-evaluate and only we can deem ourselves to be flawed or deficient or unworthy I mean that can be influenced by the environment around us but only we can feel the way we feel about ourselves so it is a uniquely individual emotion and it's idiosyncratic in its individuality no two people are going to experience shame the same way but while shame does have a major individual and cognitive dimension to it it also has a very potent and important relational Dimension shame comes about through our interactions with others it is something that helps govern our our social behaviors with other people it's often the avoidance of shame that drives our behaviors not just the shame itself shame can circulate among people it can circulate on a team it can circulate often down a hierarchy or down or across power differentials so it it has a very important relational component to it um and some would argue it is always a relational emotion because of that imagined or real other person and their judgment but shame also has something you know even more sort of um uh broad than that which is its institutional Dimension it can become embedded in our policies and our practices the ways in which we lay out our spaces the cultural norms that we establish um and it's not just that shame is embedded but it's the tendency to cause shame that can be embedded in these um policies and practices and material conditions so for example the morbidity IM mortality conference is a tried andrue practice of the medical education profession that can cause significant shame depending on how it's executed remediation practices hiring policies um State Medical Board proceedings all of those have the potential to have shame embedded in many Cas cases they do and then finally and sort of most broadly shame is a societal emotion it has a very powerful societal dimension mention shame shows up in marginalization in oppression in power in conflict in war it's often Luna describes it as the affective arm of those broader societal forces it's what makes people feel unworthy or not good enough or powerless because of a mechanism like marginalization or racism or oppression so shame is deeply embedded in our social structures and it can be embedded in our ideology so much so that we don't even realize it existence so this is overwhelming and it's entirely overwhelming when we work with shame because if we're going to really make change with this emotion in constructive ways we have to attend to its Dimensions at multiple levels which means that we have to work with it at multiple levels and I'll tell you in a little bit how we're doing that okay I'll bring you to the Fifth Dimension in just a few minutes there's one other to tell you about another metaphor I want to introduced because I can't help myself and uh think and dream and talking metaphors is one that is overused but is so apropo here and it's the the metaphor of an iceberg um our understanding and our conceptualizations and our conversations around well-being and the lack thereof and Healthcare are deeply anchored in experiences that we can measure you know principle which is burnout and those that we can more easily talk about um either because they've been things we talked about because they've been described well because they're not stigmatized Etc and that's led to you know conversations for example around transition periods that are largely weighted in the stress that they can cause the burnout that can be associated with it even the suicidality which we can more easily identify is tragic and as awful as it is what we what our what our conceptualizations are lacking profoundly is understanding of awareness of and conversation about the experiences like shame that are not so easily talked about that are stigmatized that are taboo that are really really personal for which we don't have easy tools to measure it and we don't have um entire conferences about its existence these experiences are critically important yet in line with that present absence concept are are not attended to to the degree we need to make the type of progress we want on challenging issues like supporting the well-being of trainees during transition periods this Iceberg metaphor I think also works and applies when we think about what we're observing in medical Learners right so above the water above the surface we see things like how they're performing we see things like their competency development their professionalism what they're wearing how they're talking how they're interacting with patients and one another we might see some signs of outward distress that we can identify we might give them a scale that can tell us how they're doing doing or feeling um for things that we can measure what we don't often see is the the self- evaluative or self-conscious processes going on underneath the surface that for reasons I'll explain don't often come up and some of those reasons are understandable and and um you know reasonable when we've looked at shame um and the nature of Shame experiences in medical Learners transition periods come up over and over again and we think it's because there are certain elements of the shame experience that drive it that exacerbate it that prolong it that are particularly Salient during transition periods and that we've observed as being present in transition periods and so some of these beneath the service processes include the the the struggle with going from objective to subjective standards this is particularly you know um relevant in the transition from preclinical to clinical learning in med school and then from you know med school to residency where we had a participant say about being in a clinical environment where he was being constantly evaluated and given subjective feedback he said God it's so hard it feels like I'm just being measured more and more with less and less of a measuring stick so the absence of scores of the um of relative performance to others of class ranks of board exams Etc which provide discreet markers of how I'm doing now those are gone and I'm Reliant now on information that's a lot Messier it's a lot more subjective it might not be delivered very effectively and I'm left trying to figure out not only how I'm doing but how to feel about myself as I'm doing it right and so what we find is that in the midst of that subjectivity particularly if the information isn't presented very effectively or is you know um negatively presented in ter terms of mistreatment that self-worth can take a a real hit ESP especially if that selfworth has become attached to performance over time and and that is something that we found widely across our data set was what psychology describes as performance-based self-esteem or that's the feeling of being worthy because I'm performing at a high level and so worth and performance become linked which is somewhat understandable you know we all probably have a degree of that but over the course of Education with continued high performance objectively in particular comes continued selfworth and and then that relationship is carried into clinical learning environments into residency where struggle is inevitable low performance is inevitable and even in the midst of decent performance the subjectivity around the the communication of that performance is um so challenging that selfworth then takes a hit and and another way to to state this is that in order to continue maintaining self worth I have to continue performing at a very high level which is impossible in the course of medical learning if we're doing it right so this this objective to subjective transition and its effects on self-evaluation are so important in understanding what's going on under the surface as Learners transition from one phase to another in clinical training another is the fact that identity is constantly and majorly shifting at times across these transitions I think this is probably the most sign it from medical school to residency um I was a program director for many years so I saw this firsthand and the the the shift of going from who I was back here to trying to figure out who am I now in this new environment with these new sets of um challenges can be really abrupt and it can be especially abrupt for people who aren't represented in that environment um and who then have to find belonging that other people are afforded much more easily but I really want to also highlight here this is one of the most important I think takeaways if you're going to take something away from this talk is that we need to expand our the conversation around identity to include self-esteem and self-worth the there's an umbrella concept for both of these from psychology called self-concept and self-concept comprises identity plus self-esteem so it's who am I and then how do I feel about who I am who am I becoming professional identity formation and then self-concept formation would say who am I becoming and how do I feel about who I'm becoming and what governs how I feel about myself what governs from where I derive my selfworth this is a a question that we do not attend to very much in medical education and I'm going to argue that it's critically important because those sources of self-esteem are constantly being negotiated and that negotiation is constantly under duress many people come into medicine with feeling good about themselves because of relationship because of hobbies because of service because of spirituality and the necessities of learning medicine often Force us to pair those down to put them to the side to make room for the the the increasing amount of self-worth that we derive from how we're doing as a learner how we're doing as a clinician um a practicing physician down the road that imbalance can be especially challenging when we're struggling at being a medical learner struggling at being a physician and the sources of self-worth we used to draw on to feel worthy are either no longer accessible they're not prominent they haven't been maintained and and now we have a precariousness in terms of how we feel about ourselves as we form this identity so I think a huge part of the work of of of this concept is figuring out how do we support the broad-based self-esteem of our medical Learners and understanding how our systems make that really difficult and I'll give you some things to think about at the end a part of the under the service milu is also the intense pressure to perform and the pressure to prove myself of wor as worthy of being at the place I'm in now of being in this your residency program of being a you know in the surgical field of being in this medical school to begin with that I have to prove myself to you while I perform as I'm learning and then finally kind of linked to that is just the intense impostor syndrome that can exist and often does exist beneath the surface especially in those early parts of a transition where I'm given responsibility I'm looked to for answers and I don't have or perceive that I have the skill set to do it confidently yet and then I can blame that on some system that let me in that it shouldn't have some set of circumstances um that got me where I am and not the achievement that I've um garnered along the way this millu is something we've got to begin talking about understanding and operationalizing in order to provide the level of support during transitions that our Learners most need and that's because these things influence how they feel about themselves how they see themselves and that influences how they show up how they engage their well-being their learning their relationships both constructively and less constructively and and I'll talk a little bit about the more constructive elements in a minute it's not surprising that we don't talk about these things it's not surprising that they remain beneath the surface and it's because I think those conver ations either don't happen can't happen or start to happen and they get sort of dulled out by the culture by the busyness by the demands of the world around us in medicine I think there are some key features of our culture in our research would would point to these that stimy that conversation or stifle it one is that we tend to see vulnerability as weakness or um stoicism as strength and that is that is a real cultural phenomenon that inhibits progress in this area reputation is so important um and I'm not saying it's not it is important I think it has incredibly outsized importance especially when you talk to the everyday medical learner who's so scared of loss of face loss of reputation being judged when they struggle Etc I mean over and over and over reputation comes up as a Salient um consideration and judgment is feared you know we're a pretty judgy group of folks I mean we need to be honest about that and if we think we aren't then just open your ears to the ways that people talk about people's making mistakes or people struggling you know how the water cooler gossip happens I mean there's a lot of judgment that happens I think we fear judgment far greater than it actually happens but we live in a Culture of Fear around being judged the cool thing about that is that we can change that like that is something we can change some of these other things are hard can't change the system in many ways but we can change whether or not we judge or feel judged and then finally one and what shame is just frankly Taboo it's just an icky concept it's not very fun to talk about or think about or admit or open um discuss so these are headwinds but the great thing about all these headwinds is that they can be addressed and changed and and one of the big key steps to changing them is just to start talking about this emotion as a normal emotion if we don't it's going to remain hidden right we naturally want to hide our shame it makes us feel imperfect and vulnerable it can make us feel shame for feeling shame and so the natural tendency is to try to to to to hide it this is especially motivated or relevant within public settings where we need to hide it from the people around us who might be judging us medicine is such a public learning uh Endeavor uh and then when we do perceive their judgment is even more more sort of motivating to to hide the things about which we're insecure or or the things about ourselves that we we deem as unworthy in the act of hiding that we often engage in behaviors that bypass shame and so there's a body of work from Donald Nathanson who's described the shame Compass which is sets of behaviors that help us move around shame rather than through it so it's a way of distracting from shame or avoiding it or repressing it through other behaviors um and we have a great example of that from our research of a learner who went through a very painful shame experience when he wasn't elected chief resident he had piled just massive amounts of selfworth on that the validation that that would provide um he had limited self-worth from other sources and and so much came from how he was perceived by his peers and being seen as smart and being seen as trustworthy and then they didn't elect him Chief and it led to a massive shame reaction in the midst of that shame reaction he remembered feeling he said uh quote I was a slave to my more primitive impulses and he said I just wanted to make someone else feel bad so that I could feel better and in the middle of that sort of emotional state he cussed out an emergency medicine attending who gave him some constructive feedback and he did it publicly and he went through a major remediation process that he he reflected he said um the program descended upon me rapidly later that day which is the program director I can relate to and that process induced his shame or exacerbated prolonged it significantly and it's because that process did not realize or acknowledge that there was shame behind the wall what that environment was seeing what the people around him were encountering were actions were projections of shame that were meant to hide it and and work around it even to himself I mean it took in this interview half the interview even to get him to begin acknowledging that there there was shame there at all and that's because it was he was trying to keep it hidden and even of consciously hidden and instead acting in ways that garnered really challenging responses reactive responses punitive responses that only deepen to shame so the concept here is that before we react to these challenging behaviors that may induce very difficult emotional reactions in us we've got to be able to pause and think about what could be going on not only emotionally in this learner but at the self-conscious emotion level so we this is a drawing that I made and just an early analysis and we we sent it off to academic medicine with the paper and they said this is great um it's good good concept can you pay a professional please to um illustrate this so this is what we came up with and I think it really is an important Mantra to consider as we work with challenging behaviors especially on professional behaviors um and finally we've come to Hannah mum who's really put the icing on the K here with her rendition um this is really really important and I think many of these behaviors we are likely to see during transition periods as people struggle we need to be able to recognize them as indicative of the possibility of underlying shame certainly not the inevitability but the possibility The Fifth Dimension I want to tell you about as I pivot to the last you know portion of this talk which is what do we do about this um is the The evolutionary dimension of shame and this has been such a godsend coming to understand the evolutionary dimension for me as a shame guy because it it's hopeful it's a hopeful Dimension it's also a very normalizing Dimension what the evolutionary Dimension says and primarily from evolutionary biology is that we are stuck with shame for a reason it's here in our human capacities because it's really helped us along the way as a human species when we were out on the tundra alone you know the middle of the food chain the thing that kept us alive was cooperation Community collaboration the thing that kept our genes going to the next um you know generation was the ability to stay in relationship with people shame became one of the most powerful markers or signals that I was about to transgress that group's Norm or it could become the mechanism through which I was ostracized outside of that group and then hopefully reformed my behavior and came back in still serves very important roles in our society in fact I would argue that we have far too little shame in certain you know actually major segments of our society right now that are presenting major problems we need to be able to feel this and we need to be able to regulate our social behaviors in so far as we do that shame is a normal human emotion and this is so powerful because so often we want to just dispatch with it we want to not feel it we want to just be shame free shame free is bad bad we don't want to be shame free we want to be shame engaged shame aware um you know and we want to avoid inducing it so because shame is a human emotion when we feel it it at a fundamental logical level simply just means that we're human and we're not broken and we're not unworthy but we have to do something with it and do something about it and in so doing shame can become a really constructive emotion and we have data this is Amalgamated data from across our studies not even an extensive list where we found important healthy outcomes in the processing of Shame now these were not passively achieved it was through processing it was through active work um that these these occurrences happened and and what we really shifting our attention to now and a lot of the work we're doing is how do we leverage shame so how do we leverage the shame that we're never going to get rid of while eliminating or mitigating the shame that isn't necessary in our environments and I think this is the ultimate question that all this poses to us if if we're going to do something about this which now that we know about it we have to so I'm going to try to answer that question in the last few minutes Che my time perfect um so I want to acknowledge you my colleague Luna here uh just very intentionally Luna is an academic philosopher at exiter she's an amazing academic partner in this work and just person she has expanded my thinking so much um and Luna's really the one that initially termed coined the term I going to tell you about very soon after which she and I began working to to build an entire framework around it so I just had to make sure Luna is acknowledged in this work the term I want to tell you about is called Shame competence and this is governing the implementation work that we're doing with this topic shame confidence is not shame resilience it might lead to some resilience but this is not a character trait it's not something that you either have or you don't and you can't develop this is a set of skills and principles and practices that we all can learn and not only can we learn them but we can apply them throughout our institutions so what shame competence entails or gives us is the ability to be aware of shame to recognize it to avoid inducing it and to support others and ourselves and proactively engaging with it in order to leverage its pro-social potential and mitigate its destructive potential so this gives us a set of abilities and we have conceptualized different levels of Shame competence and what I'm really maybe advocating for here is just the very foundational shame competence that we can start and begin implementing that I think in and of itself can be transformative we've articulated Five Pillars of Shame competence and we do work around each one of these in terms of bringing it into an organization a group of people or an individual and I'm going to interweave these five and what I'm going to tell you next but um if you wanted to read about them explicitly we have a little article in the lanet where we outline some of this in a fairly approachable not overly wordy way that um is is a nice overview the first thing I want to tell you about or suggest to you in terms of applying shame competence to support you know Learners through their transition periods in a healthy self-conscious way okay that's what this is these suggestions are about is first to recognize that period as high risk for Shame by virtue of the nature of that period the uncertainties the high stakes the new environments um the lack of intrinsic belonging and some of the characteristics of medical Learners them and ourselves right our perfectionist Tendencies our tendency to compare to others our mindsets and their tendency to be fixed Etc okay so this is just a high-risk period for shame doesn't mean that everyone's going to feel it or it's inevitable but it's likely to occur and if we can begin to conceptualize it that way it means we need to begin recognizing shame and and doing something about it as a part of this acknowledgement we also have to acknowledge the flip side of that which is what do people need to be emotionally healthy especially at a self-conscious level to feel worthy they need to feel valued and they need to feel nurtured and they need to feel cared for and these are fundamental human needs that yes medical folks need too just because we can hold ourselves to higher standards just because we can teach ourselves some emotional distance that's necessary doesn't mean that we don't have these needs and therefore it means that our environments have to meet them I don't think every medical learning environment is one that makes people feel nurtured cared for and valued and in fact I might argue that it's a minority of them that do this diffusely I think this is a huge charge and challenge to us and as folks who govern these environments um in operationalizing shame awareness it's it's looking out at people at your environments your programs and thinking as they go through these experiences how might they be feeling about themselves you know not just how are they feeling right how are they feeling is is the more kind of superficial question it's a lot easier to answer um right I'm feeling frustrated or sad or happy or burned out but how are you feeling about yourself as you go through this and that's an important question to ask is a part of Shame awareness if someone's struggling it's a totally okay question to say can you tell me how you're feeling about yourself in the midst of this struggle not just how are you feeling take it to the the self-conscious level and and in the right level of trust psychological safety um you'll be amazed at how ready people are to answer that question for you we need to begin recognizing shame um this is a whole talk for another day but there are ways that we can recognize it it has a phenomenological profile that that makes it you know recognizable in the way that people talk and carry themselves their action Tendencies um you already saw some of the behaviors that can suggest the presence of Shame shame we have to be able to look for those and then when we see them consider the possibility that shame is present okay so essentially we're asking for the adoption of a shame lens it doesn't mean that that lens is 100% always going to tell you that shame is there nor should you ever assume an act upon its um assumed presence but can we begin potentially identifying it and then opening the door for it to be expressed and shared and then engaged with and I think that's our next challenge we need to his third the third pillar we got to eliminate intentional shaming from our culture this is a long Workshop I I do another day about shaming it's the the act of causing shame in another unfortunately intentional shaming has been used as pedagogy for many many many years in medical education and it's still used today often with seemingly good results the challenge is that we don't see the emotional impact that it has because the shame part of it is hidden we we ly and I we consider shame to or shaming to be Mercurial it's like you're acting with an working with an unstable element you don't know how the person's going to respond to that shaming behavior and even when it seems constructive there's a very good chance you know as one participant said wish I could have learned how to treat a pneumonia without all that emotional baggage that came with it we also need to look critically at our structures in our organizations in our programs the in our cultures the way we do things talk to one another the way we govern ourselves where shaming or the potential for shaming could be embedded within them and then once we identify them which I think is a body of work we need to then modify them to reduce their int their potential to cause shame um and I think there are some really basic ways we can do this by just paying attention to our language paying attention to the way that we frame the the things we do paying attention to how a process might be making someone feel about thems it's it's actually not that hard you just have to apply the right lens to to consider it and then we need to stop the cycle of shaming right if we see others shaming we need to call them in we need to help educate them like hey there might be a better way to do this we've got to be Advocates you know for for stopping the intentional shaming that's surround us and then if and when we accidentally shame people it's going to happen we do everything right someone still feel a shame we need to apologize and repair I think we grossly underutilize apology and medicine and medical education and it's really a way to humanize ourselves and and to build closer bonds even when we fall short of our standards last couple we've got to support broad-based healthy multifocal self-esteem in our Learners um and there are some upfi battles we're fighting particularly around the ability for people to be self-expressive in authentic ways is a white man in medicine who presents himself in accordance with his gender identity and sexual Orient ation I um I have massive emotional privilege when it comes to my ability to safely self-express um in my environments it's a huge privilege to not have to switch to not have to assimilate to not have to change myself depending on who's around or where I am that privilege is deeply inequitably afforded in our environments and it has huge impacts on people's sense of self self-worth and their tendency to feel shame we have to do a better job of letting people and then not only letting them but celebrating them as the very diverse people they are and then in supporting their continued maintenance of the sources of selfworth that make them those diverse and and dynamic people and then finally we need to begin cultivating the ability to support people through shame once we recognize its presence we need to be able to normalize learning as struggle um I I really like to help people in residents partic particularly Junior residence students a little harder later in residency to really lean into the idea of being in rehearsal and not performance because that's what they're doing you you are not performing when you're learning you're rehearsing when you're learning helping them understand their their experience as rehearsal can really free them up to be more imperfect to struggle and to learn from that struggle and and not to feel shame about it to name and validate their emotions misss you know I I can tell you're really beating yourself up here it's an understandable way to feel right I've felt that a lot of people felt that actually has a name it's called a shame response and it's a really normal human emotion and I know it's hard and then to orient them away from damaging self assessment to something specific that they can change so I want you to stop beating yourself up for a minute leave yourself out of this what did you do that needs to be improved what did you do that led to this outcome and how are we going to begin fixing what you did or what you thought right or what happened um sometimes it's just a circumstance that has nothing to do with a person right this was just a really challenging vacuum delivery in a baby who was dying in a parum you couldn't see because there was blood everywhere it's not because you were a bad doctor because it was a hard situation we need to highlight incremental growth over time we're working with a generation of Learners of which I am a part that wants to be good right away we don't want to be inom and we don't want to be incompetent for long and medical learning just doesn't work that way help them see the growth over time especially amidst the failure that can be some of the strongest Catal of that growth sharing your own experiences can be so transformational especially if you're looked to as a mentor or someone towards which people are striving to be um to to say hey I've been through this before and it was really hard on me um can I tell you how I went through it you know can be so humanizing and then finally partnering partnering and offering con assistant sustained support in my shame experience I needed support for days to weeks it was not a one anddone thing um that active partnering of sharing our own experiences of normalizing the emotion of making it okay and then opening the door to talk about it not only Des stigmatizes it but it it it allows us to begin engaging with it in proactive constructive Community Building um and connection building ways and I think that's our ultimate charge so with that um I'll thank you for your time and attention and and be glad to take some questions well thank you so much Dr bam that was fabulous great intro to shame and some um recognition of it and how we might address it in a constructive manner um what kind of questions or comments do you have for Dr bham anybody um we had some great questions last night we have a few minutes left um one question just came through about going back to the previous slide yeah yeah yeah this is a I mean I've done entire workshops on this set of this one slide so I know it's kind of a fast and furious thing um but yeah there's a lot here wonderful thank you for moving on back others questions comments we've got some comments about how what a great session Oh Shannon I see your hand yeah hey um I'm a DUI oncologist so I did OB for my first four years so I hear you um and I know what you're talking about and it I think it might get worse in do anology um how do you you made kind of a comment about it being harder to um reach those uh our Learners the higher they get up in their training um and I find that that's really challenging in a surgical subsp specialy given that you know we as J and oncologists are kind of the primary surgeons not only but we they spend a lot of time with us and you know by the time they're in their fourth year they're feeling like they're ready they're already doing it and they still kind of have a lot left to learn and I feel like there's probably a lot of this negative processing because they want to do well for us I don't know I just do you have any tips for kind of reaching those more like Advanced timeline Learners um yeah because yeah yeah no I mean it's a great question um I think you know one of the the facets of that experience that might be relevant and important here is that what is what is often perceived or received as someone who appears really confident uh and and like they don't necessarily need more um advice or training or need to think about new ways to do things is that that is probably a quite curated and cultivated confidence that may not reflect what they internally actually feel which is insecurity and and uh doubts and and there's this kind of um I hear this all the time from Learners they'll say things like I'm supposed to be I'm not supposed to have to ask for help at this point in my training and that suggests that not supposed to suggest that there's some sort of Unwritten rule or standard that I'm supposed to be a certain way and you know shame comes from the failure to reach those standards even if it's like a totally normal standard to fail at right is a fourth year you know learner surgeon even as an early career surgeon like you're still going to make mistakes is a senior surgeon because the work we do is so imperfect and so uncertain that um that that Discord and the tension between my impression management and what I'm actually feeling can really be a hard bridge to cross you know if if it's only me trying to cross it so all that to say if if you can find ways to make it safe for them to express what they're actually doubting about themselves and and I'll tell you the ways to do that the biggest way is to say um when I was in your shoes I had tons of doubt I you know I projected confidence because I think I needed to my patients needed me to but in reality I was really I really had doubts about myself and whether I was going to be good enough at this you know and I don't think we talk enough about that is that something that you ever go through um or just to say sometimes what I do is like just present some of these ideas like yeah this is what Shane is is I always I do a um poll everywhere and I say has anybody ever felt shame as a medical trainee and I've never had a group answer less than 90% And that single fact is so important because it suddenly says Oh wait we're all feeling this right so then it's like well then let's talk about it so you have to find inroads to get to make it okay for this experience to happen even just to normalize it and then people will start expressing these experiences and then you can talk about what that tension is actually like so I mean there's there's other ways I could answer this I think the most important is just to normalize the experience as opposed to saying this isn't something you should be feeling thank you that's very helpful awesome it looks like uh Dr yuck has a question she's been her hand raised thank you Dr hello I'm Lisa thank you for that um I really appreciate it I was thinking in particular about the shame that happens around remediation for our training and how um whenever we have people who have succeeded a lot in their life and then all of a sudden are not succeeding it can feel particularly shameful and wondered if you had any ideas on how to you know address that and support them yeah oh man it's one of the biggest shame triggers that we've come across um and then as a program director I've I've just sat in just the shame soup with Learners who I've had to remediate um and some some really painful remediations um the answer is there are specific things you can do within that exact interaction and I think even more importantly there's things you can do within your program culture what we did in Du Family Medicine is from day one of intern orientation we we presented our what we call Performance Improvement processes you know we said they are remediation but really what they're for the vast majority of people they're meant to make you better right a very small subset or it's meant to be Regulatory and get you out of the profession if we're being honest but the majority of the time it really is to help you improve and so we would say any if you if you're find yourself on this pathway please know and trust that we are all doing it and working our tailes off to help you improve and get better now the degree to which they believe that is a little bit out of your control but but to plant that seed early and say ending up on this pathway does not mean you're broken or unworthy that we think you suck it means that we are investing in you to get better and there are skills that you need to improve and that the need to improve is a very normal part of learning okay so so you have to set a tone with it and then all of your all the language and wording around these processes need to align with that so when we talk about it in our clinical competency committee when we write the reports that go to gme Etc we make sure there's not shaming language in there we make sure everything aligns with performance Improvement we care about you we're here to support you and then within the interaction it's a lot of it is just going back to what do you need to get better at here are the things that you're deficient in you are not deficient yourself you aren't the problem it's the things you're doing that is the problem right and that's especially important when it's unprofessional behaviors or bad behaviors it's not to say you're a bad kid it's just to say you keep doing all these bad things you know I mean no one wants to be the bad kid in residency it's a stigmatized experience and so you have to get out ahead of that in front of that and sometimes it's just explicit acknowledgement I don't see you as an unprofessional person but damn this thing you're doing has got to stop right other people are going to start seeing you that way if you don't there's a whole group of ways you can do that maybe fundamentally where all that or originates is I care about you I care about you and your experience and I want to help you get better great points thank you so much so um Dr Dev I see your hands up I just want to acknowledge the time and it's 102 anybody who has to go can go Dr Dev if you want to stay after an anybody who wants to hear this question or the answer can certainly stay um and for a extra minutes if you'd like to do so but feel free to leave if you need to leave uh is that okay Dr Bam are you absolutely yeah I'm sorry for longwinded but yeah great question no um thank you so much and I don't mind people are not listening no first of all I want to thank you this is a outstanding outstanding really really enjoyed your lecture thank you um I think the I think it's not just the trainees and whatever I think it's the culture that we live in unfortunately yes it's definitely important for our learning um but I think it even goes beyond our our trainees it goes even to the levels where we are right because every day you're shamed for not you're finishing this or doing that or not meeting criteria not me so a lot of it also while we're we're taking this in for our Learners I hope I think it's been really outstanding to remind ourselves that we also feel that and then because it's been ingrained to us just as you said surrounding us uh it's unfortunately we realize we're not doing it we're we're not meaning to but it comes out that way so I really think it's outstanding and I think it needs to be carried Beyond just our trainees and it need to be carried all the way through through our culture so to speak but even you know starting with you know within our realm of environments and stuff so thank you so much I love that com I'm sorry go ahead Dr I just say it's a really important point I mean that this is not an emotion that any of us can can look at from a distance um and the best way to become shame competent is to First acknowledge it in yourself think about it forgive yourself for your own sort of things you feel ashamed about and then be prepared to support other people in going through it I think the two most important groups the stakeholder groups that are going to make the biggest change here are our institutional leaders and our faculty because there's this great montra that said if you don't transform shame you will transfer it and it it is a um we do a lot of Shame transference whether we realize it or not and instead of just saying stop doing that if we could first just acknowledge that we all are prone to this emotion that it's inevitable in a lot of the work we do and then process it healthfully it'll be a lot less likely that we transfer it so it's a really important Point thank you for making it no thank you really really appreciate you're getting us through through this this this lovely lecture thank you so much thank you yeah I did want to acknowledge that just the the point um that you when you talked about shame around needing to still ask questions right and you know I shouldn't be asking questions at this point um there there's one um Department one program in particular throughout our organization I'm not going to mention them but even though I think this is a really cool thing um where they explicitly tell their faculty you should if you have any doubt you need to ask questions you need to call in reinforcements and ask because there's this is such a high acut feel this is so um the the stakes are so high at this point with this particular specialty and um and it's it's such a sensitive area that if you have any question you call in reinforcements and you should not feel bad about it at all and and they tell their faculty this like you have any doubts yeah well then if you have if you have residents that are and students that are watching your faculty do that um right they're seeing that model but really what you're overcoming or having to overcome there is the the fear of judgment if I call and ask for help that someone might think I'm less competent or not good enough or not worthy of their trust you know you're you're just making you're creating a cultural norm that overcomes that stigma of asking for help and you know it's it's amazing in doing this work because it is such a fundamental emotion how many times I come across these wildly paradoxical um realities in our culture one of them is that we feel shame for asking for help right in a helping profession that's incredibly hard that no single one of us can be good enough at that we don't ever need help it's just absolutely agree the other is that we mistreat Learners while we teach them to become doctors I mean what how paradoxical is that you know so these paradoxes are both head scratching but they're also like revealing because it says hey this is basic stuff we can begin changing you know we just need a new approach I love it awesome thank you so very much thank you all for your thought-provoking questions um and uh I know Dr vam is totally open if you want to contact him um thereafter feel free to reach out to us or to him directly um with any sort of questions and we will have everything up um thank you for putting the shame lab in the chat we will put that up on our website with with all of the other um presentation the video all that kind of stuff so thank you I hope you all have a wonderful rest of the day and please.