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Amanda:
Hey guys, welcome back to the podcast. I am Amanda.
Laura:
I'm Laura.
Kendra:
And I'm Kendra.
Amanda:
And just a reminder to scroll down and leave us a five star review, especially write us something. We would love to read it, but it really does help other physicians who are hurting find our podcast. Today, we are going to continue our quest to increase our emotional granularity.
Giving words to the feelings that we have helps us process them makes them less, I don't know of a better word to say it, but it gives us ownership over what is happening to us when we have the words to describe the feelings that we're having. So today we are going to touch on humiliation and embarrassment, which unfortunately is a bigger part of working in medicine than Any of us would hope for, but before we do this, we will go back and touch on some of the terms that we have used before, especially in podcast number 60.
This is coming from Brene Brown's Atlas of the Heart. It's basically a dictionary for all, all things feelings. But again, it's important we do better when we can put a label on what's happening to us. So in, in Podcast 60, we talked on, about guilt and shame. Guilt is an emotion that we experience when we do something wrong.
We, things didn't go like we wanted it to. And we feel guilt because of it. Shame, on the other hand, if guilt is I did something wrong, shame is I am wrong. There's something wrong with me. And it is closely, then, related to what we're gonna talk about today. Which is, the first one is humiliation, which is where somebody else is unworthy of connection, disgusted with yourself. You may feel that it's unfair and you don't deserve it. It's unjustly being degraded, ridiculed, or put down, and it ends up demeaning or devaluing your identity in a similar way to shame. So, for example, I didn't pass my in service exam. my classmate found out and posted it on social media.
Multiple negative comments were on the post. I feel like the dumbest person in my class. And why would they post something like that to everyone? This would be an example of humiliation. Which, by the way, I did appreciate this about my med school. They repeatedly said, Do you know what we call the person who is very lowest in your graduating class?
And we would all be like, what? And they're like, MD. You're still a doctor. That also reminds me of either Outliers or one of Malcolm Gladwell's book where people at Harvard in science, the bottom third typically just drops out because you feel, you feel like you're not doing well enough, but they, they have also started doing that sort of proactive, like, no, you're here at Harvard, you're incredibly smart, even if you're at the end of your class, but anyway, that's completely off topic, sorry about that.
But back to humiliation.
Kendra:
Getting perspective though, right? A because like not everyone can be the top third. Someone's got to be the top third. Somebody's got to be the middle third. Somebody's got to be the bottom third. Yeah, that's why there's a whole class. Especially in med school. Especially in med school.
I mean, it's a great perspective to think not everyone can be top third and I will tell you that Some of the most clinically astute physicians were that I know and work with some of my brightest colleagues that I feel are clinically astute. We're probably in the bottom third academically when we were like in the book type medicine and they will tell you about it, but they are so, they have the highest clinical acumen.
So there are just sometimes when Talents are strongest in the book, like in lecture and like written tests. And those people are great. Like those people that are gifted in that fine. There are some of us that are very, very gifted clinically and our clinical acumen is second to none and may have been in the middle of the road when we were doing lecture and book work and standardized testing, but have an amazing acumen at the bedside and we need all of those doctors, we need them all.
Amanda:
So compare humiliation with embarrassment, which is I did something that made me uncomfortable, but I'm not alone. Everyone does these kinds of things. Sometimes embarrassment can be funny, but it's more of a temporary, not an attack on your, your personhood. So like, maybe you came out of the bathroom with your dress tucked into your Spanxer.
I've certainly had toilet paper on my shoe before. Or I've also said things overheard that like, probably if I had realized I would have maybe said it in a different way, unfortunately, there's lots of those, occasions, but so humiliation and embarrassment are what we're going to talk more about on this podcast.
Kendra:
Yeah, so what A alluded to, I mean alluded to at the beginning, was not so proud about how rampant this is in medicine. And unfortunately, it does start when, when, when we are in medical school, because when we, I mean, it's highly competitive. And so even amongst, you know, your fellow, you know, med student classmates, you know, you start to feel a little bit of that, whether or not it's implied or, you know, overtly like someone posting something there's just, it starts there and then, you know, it's just propagated when we go into our rotations because now we have attendings who.
Also went to med school and also went to residency and just have a way about teaching that they learned and it includes sometimes. Temping rounds, or it includes M and M conferences where a case is put up there and people get to go at it and you're sitting there in the room and it was your case and it's not so anonymous.
We all know that. And so then you're sitting here listening to the Monday morning armchair quarterback be like, why would I should I could have this is dumb. This is that should have never been the medical decision. Just all of the things. And so you can see where it's very easily propagated, and there was a 2004 survey of over 2, 000 med students in 16 U.
S. med schools that revealed 84 percent admitted they had been subject to validament in the course of their training. And this is medical students. These aren't residents and these aren't attending. So, it starts early. And, you know, one of the things we talk about all the time is the self determination theory.
And that is that, one of the principles that we talk about constantly that is a part of what helps us beat back moral injury and the, feelings of burnout that we have because we do want to be accepted. We want to know that we have autonomy in the decisions we make. We want to build that connection and belonging.
And so some of that it goes against that self determination theory. Grand rounds are pimping rounds. It's an extreme example of controlled motivation. It incorporates the shaming and this like, why would you do this? Who even would order that and all of these, like, comments that people think they're just throwing out there, but it's directed at the person that was involved in the case, and it's not so anonymous.
Any learning derived from this kind of setting actually comes at the cost of emotional turmoil. So that person is sitting there, not even saying a word because they're just like, Oh my gosh, you're hearing all these comments. You're not going to speak up and it basically sets the standard, which is something I'm not very proud of for how physicians behave and the unhealthy environment that not only doesn't fellow or foster trust, but it sets the standard for a type of learning that we're showing these med students and residents that are rotating with us.
So it's just not only. This humiliation usually lead to some sort of an angry feeling. It's not a positive thing. Usually people aren't coming out. They're going, wow, I'm sure glad they, they totally ripped apart that case and, you know, noticed every, you know, everything I did wrong. It's, it's definitely a very negative impact.
And, and people, you know, that deal with this, they can. They do have a problem with, or not a problem, but they do have a sense of ruminating, and so they'll hear that M& M over and over again, or they hear those pimping rounds over and over again, and eventually, it just makes them shut down, or just feel like they're not enough, and so, another survey which was interesting was in 2018, so like, you know, a decade and a half later, 22 percent of med students still report being publicly humiliated during med school, and most of that, they said, was by faculty.
So we just, we, we got to realize how important and how impressionable our med students and residents are and how we've really got to turn this around. Freud described introjection or the mechanism by which the individual internalized and repeats these behaviors like of us, you know, parents, peers, teachers, mentors.
That he describes it as, you know, this kind of situation where, well, I went through it. And so it's just kind of like getting what we used to talk about, like getting inducted into like a team or a fraternity sorority. Like I was hazed. It's just a right of passage or, or a principle by which you must go through because then you really can feel the pain and you really feel like that's how you get in the group or the clan or whatever.
And you know, it's that's Freud described as introjection. Medical students may be in their 20s, but, and, and even some younger than that but they're still very impressionable and they're watching us constantly. So they're not only learning, you know, how to take care of a patient, but they're also learning how to treat people and how to treat, you know, their future med students or residents that they're going to train up.
So when we talk about this and put this out there, like, what can we do? Well, how can we change this? How can we, just like we talked about, where one of the things that we are very motivated by is changing the culture of medicine and it starts with us and it's not just us three and the whole physician.
It's all of us taking our part, owning the parts we can own and you know, really be an advocate. And so how do we do this? Well, first, basically, let's not show our med students and residents unethical behaviors when we're working, not only on shift, but even when you're doing, you know, education presentations, you know, not even in front of patients or not even in front of other staff, like, nursing and tech.
Like, let's just role model some ethical behaviors. Let's, let's role model honor and respect for each other and for our future physicians. Second. We have to stop using unprofessional language, like one of the things that would really make me cringe and I and I guess I did notice it in med school I'm thinking about it though when I really became a resident Was the way that some of my attendings would treat are not like other licensed professionals, but just non physicians so nurses or even social workers or even You know, respiratory therapist, it would make me cringe sometimes at the way that they would address them.
I mean, the patient, I still would cringe. Even if the patient was unconscious, sedated on a ventilator, like thinking, okay, they can't hear you. I would still, Oh, it just made me cringe. Cause I'm thinking. They just said that like, yes, this patient is not really in the conscious mode, but that's going to land somewhere in their brain and they could, I don't know, it just, it would make me cringe.
And so regardless it, it reduces everyone else's respect for the individual saying that like exactly, exactly. And so it's just take a moment and let's just carefully phrase our comments on rounds when we're in front of the patient when we're not. When we're in a grant or a rounds, even when we're on round, like in the ICU, where it's a multidisciplinary round and you're addressing like the social worker, or you're addressing the, respiratory therapist or the pharmacist or something like.
It is important that we have this multi, multidisciplinary approach to patient care because there are so many facets, facets about the care of the patient. Not only now we have the pressure of getting them out of the hospital in time, we have the pressure of making sure they can afford their message, all these things.
So we can get dinged with and that starts with while there's still an inpatient. So just modeling the behavior where we carefully phrase our words and we just continue to honor and respect those that are also on our team to take care of this patient. It's just being a good role model. If we can start that and do that now, and we role model it for these med students or residents that we're nurturing into this profession so that they will take care of us someday, let's just make sure we're being intentional about that, example.
Amanda:
Well, I I like your word nurturing because I certainly do not feel that I was nurtured
But I think that people make the argument that these sorts of systems are set up to teach us but it's ignoring the science that when you are being traumatized or you are You know, being humiliated that your hippocampus is literally shutting down and your amygdala is enlarging and firing like crazy.
So, if you are to tell me that you're doing this for the sake of learning, then what you're doing is the opposite of your intention. And that is, I mean, If what we want to do is to teach, then we need to try another way, try another way that might actually work. Right.
Laura:
Unless you're trying to teach people what it feels like to be traumatized, because that's what you're doing.
Yeah. And I think, I think that over time, the culture of medicine has been slowly shifting out of this truly toxic, I mean, doctors used to have to live in the hospital. Live in the hospital and endure all kinds. I mean, I heard a story by a surgeon who trained in the, like in the fifties or sixties and he got, he, he was in a case where they were amputating someone's gangrenous leg and somebody made a mistake and the attending just freaked out, screamed and threw his scalpel.
And it went in this guy's forearm and, like, that doesn't happen as much anymore, but we do still have, like, we have the effects coming down through, through the generations of physicians. And I'm just, it's just so exciting to see it. It really finally starting to change because it, guess what guys, it is not cool anymore. Like people used to be afraid and think you're so powerful and such a like, you know, Oh, I would want him. Yeah. He's not a nice guy, but he's the best. No, you can't be the best. If you're not a good human being, like if you're traumatizing people, it's just not cool anymore. So I'm so glad we're making this change.
Amanda:
Well, and the other thing too, is that grace to the people who have come before us, because we, unless we are actively intentionally looking at our thoughts and our behaviors like we do in coaching, you only know what you were taught. I mean, that's the same for our parents, our parents parents. It's the same for our attendings and our attendings attendings.
each generation does a little better, but if we all start intentionally looking at this, we can certainly move it along much At a much faster rate.
Laura:
Absolutely. You don't know what you don't know until you know it. And thankfully we're learning it this. So these things also have effects on our patient relationships, the relationships we have with the people we take care of.
When I was, and honestly, part of the reason I went to medical school, I mean, there were a lot of reasons, but among them was I hated going to the doctor so much, like, I didn't know what was like, I always say if I hadn't gone to medical school, I would be. Constantly thinking everything was wrong with me because I, I didn't know what it looked like to be actually really sick and going through training helped me see what, what, what someone who's actually dying of stuff looks like, but I hated going to the doctor and I think part of it is because I didn't, I didn't feel comfortable.
I felt talked down to. And I think that many of our patients have the same experience. When I was in training, I had a patient come in with a COPD exacerbation and he was still a smoker and I was just like, well, you know why you're here. Why are you still smoking? And he, I think of that man often and I'm so grateful for the lesson he taught me that day.
He's like, how dare you talk to me like that? And he was right. And I was right, but he was right, and that was not the way that I could treat him with respect. Any number of other things. Now when I have a patient that smokes, I say, I know quitting smoking is really hard because I care. I, I always ask my patients if there's anything I can do to help them or if they are thinking about it.
And that's the way I approach it now, to be more respectful, but he really, he really helped me learn how to interact with my patients in a more respectful way.
Amanda:
I do think that patients can tell when the same exact information is coming from a place of judgment versus love, I don't think that we're not supposed to tell patients to do the things that they're I You know, what would medically be helpful, but there is such a difference in saying it from a place of grace and love than from judgment.
Laura:
Yes. And of course it's normal for our brains to judge it is normal. Our brains are geared to look for things going wrong.
However, as we intentionally practice noticing the judgment and releasing it and instead trying to replace it with something like grace or love or earnest goodwill for someone else. It is, it helps everything. So it helps our burnout so much, you guys, so much of our burnout is coming from us judging other people in ourselves.
So just as a reminder, not only will it separate us from our, our patients to be judging them or shaming them or causing them embarrassment, but it will have an effect on our own satisfaction in our careers. And it can have an impact on their health. Like they may avoid coming to the doctor because they don't want to hear it or because they've been embarrassed or ashamed before.
in a report on health related shame from 2017 by Harris and Darby of a large cohort of patients, half of all the respondents recalled one or more interactions with a physician that left them feeling ashamed. And again, I want to say it is. Not surprising. It's not surprising when we have been trained this way, that this is how you teach people is by embarrassing them or.
By pointing out what's wrong with them, we have not been modeled a different way, but now we know better, so we can do better. So, obviously, when they're afraid of being checked, and I will be honest, like, sometimes I feel shamed by office staff, like, you didn't fill out this form or, but I mean, it is amazing to me how, and obviously this isn't like shame I carry with me.
It does, it does make me curious about like, what. Why, why are these people the, like, they're supposed to be the customer service people of the doctor's office. Why are they. Not kind. Why are they, why do they love to, I don't know, it just seems like they, they like, They just got shamed by their doctor that they work for.
Yeah, maybe so. They just got embarrassed and humiliated by the physician. Hurt people hurt people. It is, that's, that's probably exactly right. Like it is contagious. So we need to notice it in ourselves and not do it to other people. Stop it. So when they're afraid of being shamed, they won't seek treatment.
They may not tell all the details of whatever is happening, either mentally or physically. I work in the pediatric emergency department. Sometimes it's hard to get all the details. You know, if I'm, if I'm coming in there judgmental about this teenager having sex. I'm not going to get the details out instead.
I may say, Oh, sometimes some of my patients come in with this kind of pain and, and, you know, they have a boyfriend and it's sometimes it's coming from having had sex and gotten an infection. And instead of like. Are you having sex? You know what that, I mean, and honestly, we can still communicate the same information in a nonjudgmental way, in a way that honors that person's agency.
Hey, just so you know, there is a lot of gonorrhea going around right now, and it is not always responding to the treatments that we usually use. So if you're worried about that and you maybe don't want to do, get that, this is, these are the things you can do to help prevent. Getting these kind of issues.
So that's the difference is, you know, you're honoring the person's ability to make a choice for themselves and still honor them, honoring them as a person instead of shaming them for being bad and making a bad choice or a choice that you don't make, does that make sense? So sometimes people have a diagnosis that they're trying to hide from their family or friends because of shame or embarrassment.
And that also can affect their outcomes. If we can help provide a safe space for them and say, you know what, we just want to make sure that you are as healthy as possible. Let's, this is okay. We can help create the safe space for you. That is going to be a way that we can help them and help ourselves. We always feel so much better when we have this kind of real, genuine human connection with the people around us instead, where there's love and positive energy being exchanged rather than shame and judgment.
So sometimes they're afraid of a like physical pain from a procedure or from being exposed even like emotional pain, they might be afraid of, and they might be afraid of judgment and that can make them avoid seeking medical attention. It's so helpful for us to pay attention to what it is that we may be bringing to any encounter.
And if we are bringing any level of judgment for that person, it is going to affect not only their experience, but our own. So it's helpful to go in and just remember, every person is here to have a human experience. They're here to learn. We're here to learn we're here, but we get to choose everybody gets to choose and people usually are choosing The best they can with the knowledge that they have even if they're not We're gonna feel better if we just believe that if we just believe that they are doing the best they can it helps us stay out of judgment and in the burnout that that can create for us and If we can provide a safe space for them where they don't feel judged, we're, we're just going to have better patient outcomes and more connection with them.
And ultimately just feel better about our experience in medicine.
Amanda:
And I'll say to the people out there that are not perfect at this, I have done my fair share of eye rolling. I still do. And sometimes I just cannot help it. Like, I don't know if it's transference or what. But sometimes. I cannot hold the space, but in those patients, I am aware that I'm bringing something to the table that I shouldn't be, even though I'm trying to get rid of it.
And so I give those patients extra grace. Like I might even overwork them up a little bit. Like my tendency is to, I'm at least aware that that's happening. And so knowing that, I'm going to be extra careful. With that patient because I know like I'm my judgments affected like it just is and yeah that that has saved me a couple times because they can feel when you're not coming.
Laura:
Yes completely open Yes, absolutely. And, and we get tainted by the other staff a lot of times. Yeah. If we are not keeping a totally like a totally clean mind about every patient, you know, Oh, they're just drugs. I mean, I had one years and years ago, the nurse, this was actually even before we had a computer based.
Patient tracking system and the patient was in a different area of the department and we relied on that patient coming on that nurse coming to tell us that there was a patient in there because I couldn't see them visually and she finally came and she was like, Oh, this guy's drug seeking, blah, blah, blah.
I went in there and. He, and she had waited a while to tell me, and I went in there and looked at his EKG. It was really low voltage because he had an EF of like 10, but he was having an ST elevation MI. And I was like, how many times do we do this? So you're like pre judge, do we just assume the worst? And anyway, thankfully I, I did not assume the worst and got him the care that he needed, but it was very, that's, that just can happen.
That just happens a lot amongst a group of people who are understandably feeling emotionally exhausted, who experienced a lot of secondary traumatic stress. It's completely understandable to feel crusty about our patient population, which is not, it's not, you know, always a great, easy group of people to deal with, but we will feel better about the whole thing if we can just center ourselves and say, okay, okay, well, let's just see what's really going on with this human being who's in distress of some sort.
And, let me just. Let me try to go in there with a clean mind and an open mind and without judgment, treat this patient like a human being.
So, as you can see, I mean, guilt and embarrassment and humiliation and all of these things, they definitely can connotate a real negative interaction, not only between us as colleagues, but us as the patient physician relationship, and also us as mentors, trainers, educators.
And so hopefully we've been able to shed a little bit of light on the situation, if not just to make you aware of when it happens. Because sometimes, you know, you do these things because it's just like, What everybody does or what it has always happened and it's not and awareness usually is the first step and so Hopefully you can think back if you right now are having med students on your service or residents on your service Or even how you interact with your interdisciplinary team if you're a hospital based physician just keep in mind you know the best way to foster Collaboration and cooperation is by just keeping that attitude of honor and respect that everyone has something to bring to the table Everybody has something to contribute and sometimes You know, it's not always relevant for the situation or may not seem important to you But maybe to their specific, you know specialty practice of specialty or whatever that it's important to them So just keep in mind and just even allow some space for that And then if it is totally off base or you feel like it's not quite right Maybe just hold that person to the side so it's a more one on one, more intimate interaction instead of calling them out in front of the entire group or calling them out, you know, in front of the patient or whatever, just a few things to keep in mind.
So, thanks for the awesome discussion today, ladies, and we are excited to announce that back by popular demand, our free webinar, what's the ICD 10 code for injuries sustained in a dumpster fire will be live at 12 PM. You can join us at that time. All you have to do is click on the link in the show notes to get signed up and go to our website www.thewholephysician. com to find out more information. So until next time, you are whole, you are a gift to medicine, and the work you do matters.
