Physician Shame, Part 2
Shame is something that can be internalized and do great harm to the individual and the people they are in relationship with. The impact can be devastating, immobilizing, and self-destructive.
As a recently retired Ob/Gyn turned coach for physicians, I hear from practicing physicians, residents, and medical students that have been shamed and humiliated at work, or feel shame at any number of perceived failures, or less than perfect actions or outcomes. Many have also experienced their self-inflicted sense of shame around such circumstances as medical mistakes, patient death, preventable (in hindsight) complications, failure of board exams, failure to see enough patients in the allotted time, not enough RVUs, and feeling like there is little time for spouses and family. Even illness, or pregnancy and maternity/paternity leave, can be experienced as shameful in the current medical milieu. In my opinion and on the surface, these are not shame-worthy acts! Humiliation as a teaching tool, hierarchical bullying and harassment, exploitation as human labor, and administrative disrespect in the form of quotas and loss of schedule control, is not acceptable and it is ever-present in the ethers. Many physicians that look like they have it all together may actually be pretending all is well, and doing their best to keep it together. Really feeling and dealing with an emotion, such as guilt and shame are seen as somehow a luxury, for fear of being seen as weak, incompetent, not worthy. For my colleagues, I am not saying something you do not already know. How many more writings and articles are we going to have to keep reading? The “I’m fine because I have to be” is actually bankrupt – given time. Unexamined, internalized shameful, humiliating, or even embarrassing emotions, thoughts, feelings, or physical experiences can manifest is many ways.
For my colleagues, I am not saying something you do not already know.
I am clear that I began my medical training as a set up for shame. I was the perfect (get the word ‘perfect’) vessel to hold it. I was recently looking through a “Baby’s First Five Years” journal that my mother kept (Instant Mama doc shame there, I couldn’t even keep up with a year with my own first of four children!). Now, I know my mother loves me, and I know to my core my father does too, but I was either a good girl or a bad one in their speaking and actions. My mother wrote “Robyn wasn’t a very good girl for her daddy last night” when I was only weeks old. How am I supposed to be good as an infant? I learned to be perfect and pleasing (great traits for a doctor). Fast forward to my early teen years and I can remember standing at the foot of the large cross in the front of a Christian churh, feeling small and guilty. I was thinking in my good girl brain, “I must be an awful person if Jesus had to die for me”. For real, that is what I took away from being good in Sunday School! I realize these snippets of childhood are funny now, but in remembering them, I see the nidus for guilt and shame to be built upon. It was a set up from the beginning (no matter what profession I chose, by the way), but boy howdy was I set up! I was the perfect little girl when I entered medical training.
What I have found in this journey of self-reflection and healing is that there is not much literature on the topic of physician-specific shame and trauma. In my current search, I found commentary and educated opinion, but few actual research studies. Currently, we must extrapolate from the psychology literature of other populations, such as veterans and children. As we already know, there is an alarming rates of physician suicide – it seems imperative to examine the experience of shame as a contributing factor.
So, why? Why don’t we have studies? Lazare, from his 1987 work, Shame and Humiliation in the Medical Encounter, puts in perspective.
“…it is shameful and humiliating to admit that one has been shamed and humiliated.” Lazare
We are stuck. Most doctors and administrators do not want to talk about it. Instead, shame is held in secrecy and silence. From experts in shame, we are told that shame is a universal human emotion. After all, we are human beings, right?
There are seven factors that make it distinct from other emotions:
- Shame is an emotion of ‘I’, who I am as a human being on this planet: I am wrong and bad. Guilt is different in that it involves the behavior being wrong and bad, separate from our core being.
- Shame is a social emotion. It is the fear of loss of connection, or not being worthy of love, acceptance, and belonging.
- Stigma and shame are wound up together as a social/cultural phenomenon, having social, political consequences, in addition to the emotional experience.
- Shame is underground; not in full view. In fact, it may blindside us, immobilize us, and otherwise trip us up at the most inopportune times.
- Shame can fester, isolate us, show up in our bodies and health, and impact our relationships.
- Shame is sometimes used as a tool to manipulate behavior and conformity- ‘excellence’ in our field.
- Shame does not survive in the light of day; authenticity and vulnerability are the prescribed treatment (And please note that it doesn’t work too well to have an authentic and vulnerable monologue with yourself. What is called for is dialogue, connecting, and sharing).
One last thing – shame and stigma are huge factors that affect patients in working toward wellness. Unless identified and shown the light, our shame can be let loose on our patients in transference and countertransference (you can see how that gets to be an endless cycle). The same is true for attendings with residents, residents with medical students, and all of us when we go home at night to friends and family we love. We need the light!
Anytime we feel separate from our colleagues or feel that we don’t belong is professional shame; doing it’s job to keep us separate.
Researches tell us shame is good, otherwise we would be sociopaths, but a wise GP once told me, “guilt is a non-functional emotion, Robyn. Stop it!”. I would argue that professional shame is also a non-functional emotion, in a practical sense, and for the majority of us.
Stay tuned for “Finding the Light”, or Physician Shame, Part 3.
Dr. Robyn Alley-Hay