S6E4: Navigating Shame in Medicine

Lina: We are back in the studio.

Leen: Studio.

Lina: This is so fun. I can see your faces in real-time. I don't have to do a little . . .

Leen: I feel like I'm back in natural . . . Sorry, I got excited and interrupted Lina.

Harjit: I know, this just feels so good. I feel like I'm already going to love talking today.

Leen: We've got to bring some Zen into this because we are too excited.

Harjit: We are so excited.

Leen: It's been a long reunion with this mic that I've been told to flirt with for the last four years of my medical school career.

Lina: She wasn't just flirting. She was . . .

Leen: I was connecting.

Lina: She was doing a lot more.

Leen: I was connecting with my mic and these headphones.

Harjit: I know. Shall we start?

Leen: Yeah.

Harjit: Okay, you're starting.

Leen: Oh, yeah. All right. Hey, everyone. This is Leen, and we are actually in studio today. For the conversation here today, we have Harjit and Lina.

Harjit: Whoop. It's Lina's first time.

Leen: Oh my gosh. No, it's not. She's been here before.

Harjit: Oh, yeah.

Leen: Girl.

Lina: It's okay.

Leen: COVID brain. It's okay.

Harjit: Girl.

Leen: I know. It's been like five years, I think. I lost count after last year.

Today, actually, we want to talk about a topic that I think is very relevant to medicine, and it crosses many different interpersonal relationships within medicine. It's not just between provider and patients, but it's also inter-provider as well. And that topic is shame, especially shame in medicine.

Harjit: I'm so excited that we're talking about this. I think it's a concept we've talked a lot about on "Bundle of Hers," kind of the interplay between shame and guilt. So I'm really excited that we're going to be talking about shame in medicine because I think it really drives a lot of behaviors that we have.

Leen: I think it absolutely is one of those things where if you felt it because of some interaction you had as a med student or whatever in a learning environment, it really, really, really sticks with you. And it comes back and you're like, "Oh, man, what are these feelings that I'm . . .? I'm disdaining these feelings. What is this?"

But the first thing that I think about is an interaction I remember having as a med student where because I forgot to report the I&Os, the provider told me straight out, "You clearly don't care about your patients." It kind of bothers me because now I know why we need to report them, obviously. Now I'm close to the end of the residency and everything, I'm like, "I get it. I get it now, but why didn't they teach me this before?"

And now there's always this kind of . . . for me at least, there's this urge to kind of take this shame that we often use in medicine, especially with teaching and between doctors, and I try to dismantle it because this is not . . . It just keeps bringing up bad, bad feelings throughout taking care of patients and these reminders, and then you start disdaining not wanting to go to work. And it just builds into a huge snowball, right?

I think this is a very important topic that I want to bring up now that we're in different areas, different fields, different areas of medicine, but we're kind of coming to a close of a chapter in each of our lives of medicine.

I know Lina's coming to a close within medical school and we're both almost finishing residency, and just looking back at these interactions and how we've kind of dealt with it subconsciously or consciously throughout our practice.

Lina: I'm excited about this topic too, Leen. I think when I think about shame in medicine, I think about my whole third year and doing rotations. Every time I got questions wrong or I forgot something, like what happened with you, ultimately the emotion I went to first was shame, and a lot of shame.

And it felt like that's kind of the only way I could learn or kind of progress, was to feel that shame and then go off of that. But I don't know. Why did I, in my mind, think that's what I had to feel or that's what I had to go to?

Leen: Interestingly enough, there's actually a whole organization dedicated to this that I found online. It's called shameandmedicine.org. It's out of the UK, but it's basically studying all the interactions that we have in healthcare and how shame affects those interactions.

And especially post-COVID era, if that's what we're calling ourselves now, I think a lot of the shame aspects were really, really highlighted and put onto providers during that era. And now I think where we're on the other end of that, we're really seeing the effects that shame causes within medicine, such as burnout, disinterest, being tired all the time, self-critical.

The rhetoric that was around COVID that I think that was really implemented on healthcare providers was war-like rhetoric. "You're fighting a battle. You're the protectors of this." Or it's the opposite. "You're also spreading the disease. You're not doing enough, or we don't trust you enough, or we don't . . ."

And so there was a lot of shame rhetoric during that era, and now we're kind of post it as healthcare providers, but I think our population has completely changed mentality-wise because of it. And that's ultimately affecting the way we practice and our burnout.

We've almost had to revamp the whole patient-doctor interaction, and I don't think it's working very well. I think we really lost a huge amount of trust for something that really wasn't caused by us.

Harjit: Yeah. And I honestly think about shame in this generation versus kind of when medical schools/medical systems first started. They were in the early 1900s, right? Shame was such an emotion that drove society, right? It's tied to societal norms. It's tied to expectations. It also makes you change how you view yourself because you're viewing yourself through the lens of somebody else. That's the power shame has.

One thing, Lina, that you said really stuck out to me is, yeah, third year is where we're kind of almost conditioned to "we have to feel bad if we're doing something wrong because then we'll remember how to do something right."

But then you think about that feeling of wrongness. It's a feeling of self-disgust. It's a feeling of "no one is going to think I'm good enough for this." It's also a feeling of unworthiness. And then we go into the whole conversation of worth.

But you know what's even more powerful? Shame changes depending on who you're talking to, right? For example, living with someone, romantic person before marriage is so shameful. My mom thinks that. I don't think that.

It's interesting because shame is perspective-dependent, but perspective is shaped by societal norms, and societal norms are shaped by those in power.

So honestly, when we utilize this whole conversation of shame, it reminds me of all the things we're fighting against, right? We don't want to be in this type of system. Yes, it helped us do the right thing at one time, but it made me do the right thing because I felt bad about myself. That's messed up.

Leen: It's almost like it's a mirror projection, right? Where there's projecting a feeling onto somebody else, but then it's almost like now you're taking that projection of an experience of someone else that maybe you have given value to their word of for yourself.

So, by going through that, it will create just a continued link of chains throughout generations.

Harjit: Totally.

Leen: I think that's why shame is strongly used at least among various cultures and communities. That's how we think we can build a better society, is by continuing this projection of shame through the lens of the person predecessor to us, right?

And it's been shown over and over, especially in medicine and especially when you use it with patients, it does not lead to good outcomes.

Lina: No, it doesn't.

Leen: Right? So why do we keep doing that? And I think maybe it's something because of our own culture that we bring in as an individual into medicine.

Harjit: We also look at who is more shame-prone, right? You'll see five med students. Three of them would be like, "Oh my god, my resident is saying I'm not doing this right. Whatever. I'll do better next time." The other two will literally agonize, "I made a mistake. This is going to affect my evaluations. Am I going to be a good student ever? Will I ever be good at this job?" So everyone's shame-proneness is different.

Because of the way shame is utilized in different families, different groups of people, I would say going back to . . . With "Bundle of Hers," we try to uplift voices that are underrepresented, and a lot of people of color I think struggle with shame and we are very shame-prone. But not only powers that utilize shame, but then it impacts people like us very differently.

Lina: Yeah. And I feel, also, it doesn't just stop at shame. When you feel shame, like you brought up, Harjit, before, it ties to a lot of other emotions, that guilt, that confidence in where you're at. "Can I do this? Can I not do this? And now I feel imposter syndrome. Now I feel like I'm going to fail out of med school. Now I feel like I am letting down everyone around it." And it just goes into a lot of anxiety rather than just stopping at shame.

Yes, maybe it led us to be better at what we did wrong or what we forgot at the beginning, but then it also associated us with a lot of negative mental health aspects that came from that feeling.

And so, then, it's just kind of this cycle of, as me for a fourth-year, "Oh, I finally am doing things right," or, "I'm not forgetting things that I used to forget in third year." But a lot of it feels like I'm walking on eggshells all the time or I'm just anxious about that, and it just comes with a lot of those feelings.

Harjit: I really like that you say that, Lina, because yeah, it's instant, right? I yelled at you for doing something wrong, but then when you get those whammies again, and again, and again, it shifts the way you cognitively process information, which, like you said, has mental health repercussions. And we no longer then are able to cognitively process things quickly and be like, "Oh, that was a mistake. I made it," and not take it to such a personal level.

So I do really appreciate you saying that, Lina.

Leen: And to even extrapolate onto that, shame is definitely a tool that people in power will use to keep you in line. And that power is going to be very much either socioeconomic based, racially based, culturally based. We all kind of have an idea of who has power in various situations when you're in it.

Especially in residency, I can recall a time where I was basically told to be a bit of ashamed of my own personality within my encounters.

Harjit: Oh, you told me that. Yeah.

Leen: Right? And I think that's the biggest thing. I think if I was a med student in that same scenario where I was told, "You acting ditzy is not going to make you a good doctor. Stop it," or, "You need to make eye contact when I talk to you," and these kind of things, if I was a med student, I think I would've totally broken down and not succeeded. And easily, people would've written it off as, "Not a good student to be in emergency medicine," or whatever it is.

But I think then I was definitely more confident within myself. I believe in what I want to do. And don't get me wrong, it still really hurt when these things were happening.

But looking back at it, I think it's absolutely crazy that a person is capable of doing that and then making you feel shame, and you won't realize that it's more of a power dynamic. You think in the moment it's more you than it is the power dynamic until way later. Later, you're processing it and you're like, "Oh my gosh, that was abusive. They were trying to make me feel shame."

The thing about shame is you don't recognize it immediately in the moment because it's such an innate instinct, right? It was built upon us back in God-knows-when, just the way we were created, in order to fit into societies and things like that. So it's such an innate thing to go after that it makes you not think about it in the moment logically, just like anxiety kind of does as well, right?

But by the time you process it, it is kind of maybe too late to counteract that interaction, and so it lingers with you. So then instead of feeling shame at that point, you're feeling more angry. You're like, "I can't believe this person did that to me." Right?

Which I guess could be processed later on as in your interactions, you'll recognize not to do that, but I think it's crazy because that makes it difficult to target, especially within the field of medicine. It is not something you can act on immediately because it is targeting such an instinct within being a human being.

Harjit: I had a question. So you kind of shared your one experience of feeling shame with the ins and outs, but are there other times you felt immense amount of shame? Do you both remember, Lina or Leen . . .

Leen: I mean, by the nature of being at least a female within a very, I would say, "conservative culture," even when you don't do things, they're still teaching you to be shameful, right?

Maybe you were the perfect example of what a female in this community is and you didn't do anything that they think that is shameful, but they will still bring it up to you and be like, "Remember, that's shameful. That can be shameful."

Harjit: And then you actively avoid scenarios, making choices that would lead you towards that path.

Leen: Absolutely. And I think it takes a lot of brainpower and a lot of insight to go into that brainpower to pull yourself out of that and recognize it. I think a lot of people don't ever pull themselves out of that cycle.

Lina: Yeah, it's so hard. Similarly to you, Leen, growing up in "conservative or more traditional culture" or just in an area where you get a lot of, "Don't dress like this. You should feel shameful. Don't act like this outside the home. You should be ashamed, or don't bring shame to your family," and all that stuff . . . Yeah, I am in a situation where I'm very well away from that, but yet a lot of my other actions are impacted by that because I do not want to go down that way.

I do not want to get close to feeling ashamed or feeling that shame because then I feel all these repercussions that don't even make sense, like, "Oh, my family . . ."

Harjit: Their honor, their pride. . .

Lina: Yeah, or something. I was like, "Why am I thinking that?" And it takes a lot of mental energy for me to be like, "Where does this come from? Why do you feel like this?" And just going until I feel the root of it, and then I'm like, "Okay. Well, how can I counteract this? How can I honestly think logically of where I am right now?" Grounding myself, and like, "Will this actually happen or is this just something that's coming from your past?" But it does take a lot from me.

Harjit: Yeah, and I think about this a lot. The reason I asked you this question is because shame is a huge driver of the way I interacted with the world rather than my identity.

And I think the day that I realized that I need to drive with my identity rather than the shame that I was taught to drive with, I would be more of a powerful person. Me making a decision about the way I dress because I feel good and I feel like it represents who I am is not a wrong action. It was literally that flip for me, I think when I was in my 20s, that really helped me and grounded me and reduced my shame.

I don't know fortunately or unfortunately, but Leen, do you remember when I would get negative feedback and it didn't really bother me? It was because I had made that switch.

And also I'm older, so maybe it happened at the same age as everybody else, but I was fortunate enough to make that switch before third year, so those shameful remarks didn't impact me that much. I'm like, "That is what you think is shameful? For me, this is a learning opportunity and I'm not going to be a bad doctor because I forgot someone's ins and outs. I'll go back and read them again."

Leen: But that switch is sometimes either built into you, or not, earlier or maybe later. And I think where we struggled is because it was not innately built into us earlier or even told that we could be that way. We could take this as feedback rather than shame.

And I think other people maybe, depending culture-wise, depending power-wise, when they were given shame, they were taught, "No, this is not because of you. You are going to build this into your identity and change," versus us, it was meant to subdue, right? And I think this definitely continues to come up. I mean, it's going to keep coming up because it's a very, very . . .

Harjit: Oh, totally.

Leen: . . . influential thing that puts into a person, right?

Harjit: By the way, don't get me wrong, I still feel those thoughts. I think what I'm saying is whenever that thought or feeling comes, before I try to shift it in behavior, I'm just more conscious of it.

And I say that every decision I make is my own, and it's based off of my identities. It's based off of me being a Sikh person, a Punjabi person, a woman, someone who likes blue, someone who loves to dress up and sometimes show her knees. These are the things that I have to consciously think about. It's so interesting because I try to get rid of that, but when I come back in this medical world, you see it's utilized here.

And then I had another epiphany because I was like . . . We talk about shame so much in our cultures and our families, but literally, it's happening everywhere, just like everything else. It's happening in medicine. It's happening in this community as well.

And you are right. I think it does make us burn out quicker and more quickly, because there's always this thing of, "We're not good enough, so we have to do better."

Lina: Thanks for bringing that up, Harjit. I think when I think of how I'm tackling shame, if I tackled kind of the shame that comes from my upbringing, or my community, or my family, I was like, "Okay, I got that down." But then medicine was a whole new vibe to kind of get exposed to and feel, and that took some work as well.

But I think what you said about remembering your identity and kind of using that to ground yourself and to show you the way of your decisions and what you want and what you believe in and kind of what you're tied to, I think that's a great thing to lean on in a way.

And I think you both have always reminded me that . . . even when I was a first-year and y'all were fourth-years and you're like, "No, don't think like that. Where is that coming from? Let's talk about this."

And so just constantly reminding me of, "What do you want? What do you believe in? What do you like?" and all the things you brought up, that's for sure how we can try to navigate that a little better.

Leen: I think that's a very, very crucial point, Lina, that you bring up, where the fact that shame covers up our ability to be who we are and lead through our passions, and our empathy, and our wanting to be able to contribute to our community, which definitely extrapolates, if you think about it, back to being a physician.

The aspects of shame that we are meant to feel throughout our learning career prohibit us from actually becoming that doctor that is able to fear and have anxiety and be able to process these things. And then that process is key to being able to have empathy and compassion and innovation and creativity.

And so if you think about it, the whole idea of teaching by shame in medicine is detrimental, at the end of the day, to truly making a physician that is capable of being flexible, and ready to think, and ready to change, and ready to bring in new ideas and new treatments and new plans and communication with patients, which is what we are missing in our field.

Harjit: I love that you say that. Which doctors are remembered? They're the ones that utilize their own brain, their own mind to make up treatment plans that are individualized for patients, not the ones that memorized a million different things, have the exact same plan for every single person, and get confused when the patient comes back to the office and is like, "That didn't help me. That didn't work for me."

And the only reason I say that is because sometimes in psychiatry, it gets frustrating because I have to try a lot of different things for something to happen, but it's that thing of being active and critical.

And I really, really liked how you said shame impacts our ability to feel all of these other emotions, because you're right. You work in emergency medicine, Leen. When you see someone who comes in with a broken arm, they're gushing blood out, when you have the fear and anxiety, you would take the appropriate reaction to do that work in a particular manner, to make sure that patient is safe and they are not going to pass out. You're going to stop their blood. You're going to kind of stabilize them, right?

And if you were reacting by shame, then you'll be like, "Oh my god, I'm going to make a mistake. Something is going to happen. Something is going to go wrong. I can't do this. I don't know if I can do this." It's so counterproductive, but it's so ingrained in us to do.

I even remember sometimes yelling at medical students or my juniors and being like, "Why did you do this? This is how you should do it." And then I had to step back and be like, "Wait, that's not how I should teach it."

Leen: That's key. A big thing that we battle in medicine is being jaded, being burnt out. Well, that jadedness and burnt out comes from the fact that we have been so overly anxious, per se, on the fact that, "When am I going to do this right? How am I going to do this right? What's going to happen? I didn't read this article. Oh my gosh, I missed this study. I was shamed for not knowing this study," versus the fact that, "Okay, I have a patient in front of me. I'm anxious. That's okay, but we are going to make it. We're going to channel that anxiety to make this a safe environment for this patient."

Lina: Yeah. Something else, too, is the ability to process and get through failure. I think when we have a lot of shame in us, we avoid the failure so much that we don't even process it or process why this went wrong. And that doesn't make for a very good doctor.

We all know, in medicine, there's going to be a lot of failure. There's going to be multiple tries for something. Patients are very complex, people are so complex, and it will take multiple things sometimes, and that's okay. We just have to get past the shame that we feel for the failure and look at it more as like, "Okay, well, something didn't work. Let's process that."

And instead of feeling ashamed and kind of run away from the problem, per se, we want to approach it with a better mindset of like, "How can we get through this, and how can we get in a better place with this?"

Harjit: I do really like, Lina, that you say that. I'm just also thinking about personal life, right? When I make a decision that people say was shameful and it actually turns out wrong, like I shouldn't have made that decision, I'm like, "Holy crap. Oh my god, everything everyone was saying was right."

But that doesn't really help me process the failure, because I'm just stuck on "Everybody was right. I was wrong." It's like, "Oh, yeah, I made a mistake," and then I can grow from it if I take that piece of shame out.

I think shame, like I said, is an emotion that human beings feel, and it is an emotion that is in our DNA, so it is appropriate. We're not saying no one should feel shame. There are particular instances where I think it can help guide us in the right direction, but it is utilized so inappropriately in the world.

Lina: Yeah, I think always remembering, "Where does this come from? What do I want? Is this coming from myself? Is this coming from society or family or someone with more power than me?" And then just feel the shame, that's okay, but also process your emotions and process where all these are coming from.

Leen: Shame can take away our processing abilities, our process to failure, our process of how we go through life, and this is what's key and what is honestly missing in the medical education, and maybe other education fields as well.

And so, through that, I hope for all our listeners, especially those who mentor students, who teach, who are in any sort of education sector will remember that when faced with maybe a student who gets the incorrect answer or forgets something. Are we actually giving shame, or are we going to make an environment where we're allowed to process failures and succeed from them?

Honestly, that is what we need and that is what our patients need. We need that innovation within us to continue to thrive so that we can continue to give good care.

And with that, thank you everybody for listening to this episode of "Bundle of Hers." We hope you enjoy this very, very passionate topic that I think we all are really engaged in. And we hope that you'll continue to listen to us at wherever you get your podcasts.