“Then why did this patient come to the hospital? You haven’t done anything to help this patient,” the attending physician said angrily during our morning rounds, upset that the patient had not met their urination output goals during treatment for heart failure exacerbation. A hot flush crept up my face. Tightness clenching my chest and stomach. What was this feeling I felt? Shame. The entire team attended morning rounds — the fellow, two residents, the other intern — all witnesses to my humiliation. Fifteen years later, I still remember this, etched in my physiologic memory like it was yesterday. This was one of my earlier call nights as an intern on the inpatient service, taking care of patients still hospitalized while at the same time admitting new patients. Those call nights were brutal. I was mostly following the directives of my skilled resident. We were doing the best we could to take care of 24 patients on our team the next morning. It was not surprising that we didn’t have the time to check on the urine output of this patient. This story is a rather benign one compared to others I have of experiencing shame in medicine, especially during medical training. And yet, it has stuck with me. And despite that, by the end of residency, I had earned this attending’s respect, and we now co-manage patients as trusted colleagues. I will never forget how I felt that morning during what felt like an interrogation. And the certainty that it was unnecessary, unnecessary for my formative journey to becoming a competent and compassionate physician, unnecessary for interfering with the development of my professional wellbeing. Shame is an experience all too prevalent for many of us in medical training. An aggressive Socratic method, otherwise known as “pimping” in the U.S. and usually conducted by someone more senior than you, often the supervising attending physician in the training hierarchy, is a teaching method where junior physicians and medical students are questioned while under a spotlight. This questioning continues until you have no more answers to the questions posed. Questions I remembered ranged from information about the patient to pathophysiology. Inevitably, there would come the point where I no longer could answer. And I would feel humiliated and shamed. Sometimes, this was accompanied by a condemnation of my insufficient knowledge, and usually in front of the entire medical team. It was a public, verbal flogging of sorts. “Pimping” ensured I learned the information and expanded my knowledge base, but the motivating factor was driven by fear and came with a high emotional cost. A fear of being “pimped” and shaming also ensured I often kept my mouth shut during rounds unless presenting a patient. As for the rest of the team, how did witnessing these customary floggings affect them? Postures shifted uncomfortably, eye contact was avoided, and silence reigned. Questions remain: When did such abusive mistreatment and emotional trauma become normalized in medicine, a profession touted as one of healing, with empathic and compassionate persons—and yet what we experienced was not compassionate. This story I shared with my breakout group during an online session for the Mindful Healthcare Collective this past year on Shame and Medicine: A Mindful Approach, facilitated by Dr. Patricia Luck, a session that allowed those of us attending, as one example of how shame is experienced within medicine, to examine the impact of this teaching style within medical education. Despite the social and cultural importance of shame, shaming in medicine verges on mistreatment. Dr. Luck provided a rich repository of resources on shame, including a short video from The Shame Conversation — made by Dr. Will Bynum, a family medicine physician and medical educator, and his team at Duke. Dr. Bynum’s research on shame focuses on the shame experiences of medical learners and providers in the clinical environment. Their short film shows health care professionals sharing their shame stories. It was a forceful reminder for me that the situation that provoked these feelings of shame need not define me as a health care professional or human and that I am still whole, imperfectly perfect just as I am. Powerfully modeling for us at the beginning of the presentation, Dr. Luck shared her own experience of shame — demonstrating building resilience to shame through recognizing it, speaking about it and fostering recovery through mindfulness and self-compassion practices. She shared the story of a relatively small experience that elicited a shame response — misdiagnosing a self-limiting viral rash in early career — as well as the larger experience of failing a year at medical school and thus feeling abandoned and shamed by peers. As a resilience-building response to shame, Dr. Luck recommended and led us through Tara Brach’s RAIN practice*: R: Recognize the arising discomfort A: Allow and accept it as it is in the moment I: Investigate with curiosity the thoughts, feelings and body sensations one is having in the moment N: Not identify — reminding ourselves that this moment of discomfort does not define us as humans, and then N — for nurture — using this moment as an opportunity for self-compassion and asking what is needed in this moment She closed the session with a reading of Mary Oliver’s “Wild Geese.” As she recited the line: “… you do not have to walk on your knees for a hundred miles, through the desert repenting …” I found tears streaming down my face. Why was I having such a visceral response? This overwhelming sadness for so much that so many of us in health care have gone through, are going through; for all the years of repressed trauma from shame in health care; for so much suffering. And yet, there is hope. There is always hope. Dr. Luck continued the closing meditation by guiding us in a loving-kindness practice, for ourselves, for each one of us in the workshop, and for all sentient beings. This is just the beginning of the healing. Shame cannot remain interwoven into the fabric of health care. It must be unpicked, unraveled, and allowed to fray free. Shame can no longer be accepted as a rite of passage or the norm in medical education and training. It is harming health care professionals. Wishing you well. Wishing you ease. May you all be safe and experience a sense of belonging. May you be healthy of body, spirit, and mind. May you all experience joy and ease and be at peace. Opening the circle of kindness, of care and compassion … to all sentient beings. May all beings be safe, and experience belonging, and be free of the experience of shame. May all beings be healthy, in body, mind, and spirit. May all beings experience joy and be at ease. May all beings know peace… May I be safe. May I know belonging, and be free from the experience of shame. May I be healthy in spirit and body and mind. May I experience joy and be at ease. May I know peace. Shame is not the way, but it can become a gateway, be turned toward, be given voice to and tended to with compassion, for self and others. * The acronym RAIN was originally created by Insight Meditation Society teacher Michele McDonald and reinvigorated through the teachings of Tara Brach. Source
