Shame In Medicine: What Every Doctor Feels and Hides with Dr. Will Bynum | Ep13

Michael Hersh, MD

[00:00:00] Most of us were trained to bury shame to muscle through it and to never let it show. But what if shame isn't a weakness to hide, but a signal we can actually learn from? This week on Better Physician Life, I'm talking with Dr. Will Bynum, associate professor at Duke and co-founder of the Shame Lab about how shame shows up in medicine and how facing it head-on can make us stronger.
Hey everyone, and welcome to another episode of Better Physician Life. Thank you so much for being here today. We've got a lot to chat about with today's guest, so I'm gonna jump right in. Today's guest is Dr. Will Bynum, an associate professor of Family Medicine at Duke University School of Medicine, and a proud veteran of the US Air Force.
After earning his medical degree at the University of South Carolina and completing his residency in Family Medicine with the Air Force, he went on to pursue a PhD in health professions education in the Netherlands.

[00:01:00] His dissertation focused on shame in medical learners, and it was internationally recognized as the best doctoral dissertation by the Association of Medical Educators of Europe.
Dr. Bynum is also the co-founder and co-director of the Shame Lab, where he and his team are leading important work to help the medical community better understand and navigate shame through research. Training and education, and I'm so excited to dive into this conversation. Dr. Bynum, welcome to the podcast.
Thank you, Michael. I'm really glad to be here. Shame in medicine is a super fascinating topic for me, but I know this is not a conversation that a lot of physicians, let alone male physicians, are having on a regular basis. Can you tell us a little bit about where your interest in shame in medicine came from and how it has developed?
Yeah. You know, if you've talked to me long enough, you've probably heard some version of the stories that led to this interest, but it

[00:02:00] started in a place of personal experience. I never really sought out to study shame or dig nearly as deeply as I have into it. And it happened in residency when I made an error during, patient care with a pregnant patient.
At the same time, I was just getting out of a, frankly just kind of bad relationship in which I was feeling chronically inadequate, not good enough, not worthy of, being treated the way I deserved ultimately. And these both happened right around the same time and left me just.
Professionally and personally reeling, I mean, really left me reeling and as a part of the concerted recovery efforts I undertook, which were non-linear and they were not pretty at times. But they were among the most formative of my life. I came across shame. It really initially from Brené Brown's TED Talk, I mean, I sifted through enough bad self-help.
Tools that I finally just, I think, went to Google or YouTube and there she was. And when she started talking about

[00:03:00] shame and she talked about it in conjunction with vulnerability, it was like someone was describing exactly what I was going through and feeling with a word that I was familiar with, but I had never thought of as apt to describe it so perfectly.
And it was literally like fog lifting for me. And so I came away from that with. I mean, I just sunk my teeth into anything I could get my hands on. That helped me understand shame more for myself, which was very helpful for my recovery. And then increasingly to help me understand what, you know, the experiences might be like for other people going through similar things, both personally, but more importantly, within healthcare.
And so that was the spark. And then, you know. Many phenomenal mentors and opportunities along the way. And, you know, here we are talking about it. Yeah. Love how, I think Brené Brown is a lot of people's gateway drug to conversations about shame and vulnerability. And I know I have read a number of her books as well,

[00:04:00] and I think one of the initial books that I read was, I thought it was just me, but it isn't.
And that was really. Written from a female perspective. And then I found Daring Greatly and I found the story about how she expanded this work to include men because there is this misconception that, men don't experience issues like this. Or at the very least, if we do experience issues with shame and vulnerability, that it's unspoken and we don't talk about it.
We're socialized not to discuss these things. And for me, that's been a huge part of the last couple of years is learning how to if you will, unhide myself which is something I was very good at doing for a very long time. How has that process been for you? I know how it's been for me. I'm curious about what that process has been like for you. Who publicly talks about shame in medicine all the time.
Most of the time I feel like I'm just expressing, you know, myself and being honest in a way that doesn't

[00:05:00] feel terribly revolutionary, to be honest. It doesn't feel like it at all. Then there are other times when I observe how little this emotion gets acknowledged and talked about and especially how little it gets talked about engaged with acknowledged in men that I do realize maybe there is something a little bit revolutionary about so openly talking about this emotion.
And not just like in ways that are comfortable, or well thought through, but really trying to talk about it in ways that are real. And, there is an element of vulnerability there that is a bit scary. You know, I think I've gotten enough experience talking about the emotion that my life has not fallen apart around me.
People still seem to think I'm a respectable, guy with. Plenty masculine, if that's one of the things we worry about losing is our masculinity. I've certainly not experienced any of that, but the fear has been there at times and it only has come through repetitively talking about my experiences, sharing them and being open about them to

[00:06:00] realize that no one's running for the hills away from me.
You know, if anything, I find that I'm much more connected. To people in my life, be it the people I'm really close to, and also people I'm just getting to know for the first time through these shared experiences that bind us as humans, but that we don't acknowledge or talk about. Yeah, a hundred percent right.
Because when we have these veneers up, when we have these coats of armor on, it's hard for people to really get to know us and who we are. And while it can be, The only good word for it is vulnerable. To allow ourselves to be seen for who we are. That is how we develop the closeness and deepen the relationships that we have.
Taking a step back, 'cause we jumped right into it, can you tell us a little bit more about shame? When you are talking about shame, how do you describe it? What do you talk about? There's just a huge body of literature around shame from psychology, sociology. Evolutionary biology.
There are a lot of ways to help understand and define shame.

[00:07:00] We use a somewhat of an amalgamated definition that we acknowledge is necessarily somewhat narrow for understanding, and it doesn't capture all of its elements, but at its essence, shame is an emotion that occurs when we engage in a self-evaluation either consciously or not.
And we. Deem ourselves to be in some way globally deficient or flawed or unworthy or not good enough, not blank enough where the blank is filled in by some element of who we are as a person in a more stable, fixed sense. So, I mean, it's the fundamental sort of shame self-talk from Brené Brown.
It's, I am bad. There's something wrong with me and therefore I need to fix. The problem with me, I need to fix my badness. My unworthiness which frankly can be very hard to do. It's very hard to fix things about yourself that are not easily changed. And so shame is this globally negative evaluation of the self.
It also has, what many would argue is a ubiquitous

[00:08:00] sense of negative judgment from others. So when we feel shame, we perceive. That other people are judging us in globally negative ways, often in alignment with the way that we see ourselves. And those might be real people in our lives. You know, people in the room with me when I made my error.
Or people, my family who heard about it later. It also could be projections of our imagination. So if someone was standing over there watching me, this is what they would see, and this is what they would think of me. And that often is a projection of our own self-judgment, but this painful sense of exposure and judgment is a hallmark of the shame experience.
Yeah. When I've heard you speak about this before, and you were just alluding to, sometimes these are things that are hard to change, and sometimes they are impossible to change, right? Certain aspects of our appearance or fundamentally who we are, what we look like, how we show up, and how we tie those attributes to our worthiness.
Do you have any, thoughts about that. Yeah. There's this, our research

[00:09:00] is. Shown some qualitative overlaps between shame and fixed mindsets, for example. And, you know, a fixed mindset is one in which you just fundamentally believe.
You've either got so much of something or you don't, you can only be so good at something. And then why bother trying to be better? So, shame often comes up and things like, I'm a bad test taker, I'm not a visual thinker, or I'm not good with people. Those are global descriptors about something about me.
Now, can I get better at my interactions with people? Sure. But attributing it to, I'm a little bit socially awkward sometimes with people or I get nervous in a crowd. That's a different attribution than I am just a social disaster. I'm socially inept. I can never be socially adept.
You know, there's elements of fixed thinking with shame. There's often a real perception that it's not just that there's something wrong with us, but that wrongness is the reason why things happen to us. Okay. So it's an attribution often, not always, but often

[00:10:00] to something that we've done or transgressed or some way we've been treated whereby we.
Conclude that I'm being treated this way, or I'm screwing this up, or I'm, you know, I'm not lovable in this relationship because I'm the problem, because me, like I'm too neurotic or I'm too much of a thinker. I'm too emotional. You know? And it can be really hard to fix those things if you've deemed that they are needing to be fixed.
Sometimes, rather than thinking we need to fix them, we just wanna hide them. So I'm just not gonna show you my emotional erotic side because it's too painful for me to feel shame in the ways that you react to that. So there's a host Of behaviors that shame feelings can induce the heart of them though, I'll just say I think at the heart of them is just a pretty painful emotional experience.
It can be a very constructive emotion in ways, but it really hurts to feel shame. A lot. Yeah. I mean, so that it's often, you know, the avoidance of shame that drives our

[00:11:00] behaviors and also that keeps us in alignment with important things in society. Right? I mean, that's where Shame's very constructive and that's why we've evolved with it.
You know, we're all stuck with this emotion, which is one of the reasons we think we just have to talk about this because We don't fall into, shame as a predisposition. We all have it 'cause we're all human and so therefore we have to be able to work with it and engage with it.
But it does do some helpful things for us. You know, it's often the desire to not feel shame that keeps me from doing things that I should not do. Right. I mean, in a constructive way for me is an. Someone who needs to be socially accepted and needs to have a community. And these days, that is somewhat necessary for survival.
Back in the day, when humans were not at the top of the food chain, that was crucial for survival. You had to be a member of a cooperating group of people. So you know, this is what's so fun about empowering, about working with it. It's in equal parts, painful as it is empowering, and it's the empowering part that we have to work to

[00:12:00] see and find, you know, and that's what we're all about.
That's what we're trying to do with the work we're doing. Yeah. and so let's talk a little bit about the work you're doing, so we've talked about shame in general, but you have this focus on shame in medicine and in medical education. What does that look like? How does that show up for physicians or doctors in their training?
Gosh, we could talk about this for the rest of the day because it's complex and it's diffuse and there are all sorts of interweaving. Dimensions of shame in healthcare. You know, we've done most of our academic work in medical learners who, you know, are a highly vulnerable population to shame. You could say that being in a medical training environment is a high-risk environment for feeling shame.
And I mean, I would extend that to healthcare. It's combustible. If sort of shame is a fire, then we're just working in a combustible environment. And some of that's because shame often comes from the failure. Perceived or real to achieve a standard. And healthcare is just littered with

[00:13:00] standards everywhere for all people.
Not just professionals, but patients too. You're supposed to be a certain way, you're supposed to achieve a certain level of health. You're supposed to achieve a certain level of competence. You're not supposed to hurt people, right? That's the first oath that any doctor takes.
It's the fundamental oath. First, do no harm, and it's an oath that you're inevitably gonna transgress. There's shame risk right there, right? We're all gonna transgress that oath, and then we're gonna feel about ourselves certain ways. And shame can be one of those ways. There's also a deeply integrated interweaving of our professional selves.
And what we are learning to do and who we're becoming with who we are as people, much more broadly. So this interweaving personal professional identity and the principle critical role that service towards others, competence, et cetera, serves as we develop an identity is amazing. But it's also a risk for feeling shame when that

[00:14:00] identity is inevitably transgressed or unachievable in a moment.
And if you just think back to your training, God, how many times did we feel like we were falling short of a standard? I mean, all the damn time. And you'd feel that way because the standards are really high. Necessarily. So, therefore, we're gonna fail to reach those standards. We have to be prepared for the shame that can follow.
There's also just a lot of triggers for shame, not just patient care and medical errors, but the way we're treated by other people. The sense of exposure while learning, and doing something that's very public in nature. God malpractice the public nature of that and the punitive nature, judging nature.
Also just some of the enculturated challenges, mistreatment and incivility, pimping or, questioning with the purpose of humiliating. And then also I would just say that there's pretty rigid hierarchies in power structures in healthcare that, Essentially across which shame can move very easily and insidiously So in essence, I'll say Michael, I mean I'm quite biased here and I have a lens

[00:15:00] that I look through a lot, if not all the time of shame.
But we're a very shame-rich culture. And I don't say that in an entirely bad way. I think we have a lot of unresolved shame and shaming that we really need to get a grip on. But also, we have a lot of shame that comes naturally because we're just dedicated, devoted people who are error-prone and striving for high achievement.
And when you have that, shame is gonna be a part of that experience, And that can be okay. Yeah. And you're completely right. The other area, I think where shame comes up a lot is in. Asking for help, right? So in so many ways, it is normalized for physicians to not ask for help, whether it is personally.
Or even when you're thinking in the context of work, right? When I call a consult or ask somebody else for help, what is the reception on the other side? I'm sure every emergency room physician out there who has to think about what it is to call a consulting

[00:16:00] physician and what is going to be the response of the person on the other side, like that.
Even just asking that question can be an incredibly. Shaming experience. And I say that as a consultant who has been not always the best recipient of that request for help, right? And so this is something that we all fall prey to, and there's no getting this right a hundred percent of the time, but there is raising awareness about how we show up with our colleagues.
And I think that the way that medicine has been siloed and we have been separated. Has somewhat propagated this, right? Because if you are friends with the person who's calling you for help. You're gonna respond in a way that is gonna be a lot more pleasant and embracing, and of course, I'd love to come and help you.
But when we've been siloed and we don't know each other anymore, right? And that is the reality of what healthcare has become over the 20 plus years since I graduated from medical school. And so it's really fascinating. Now, there's so much to say

[00:17:00] about all this. I'll try to say it succinctly.
The first thing that came to mind is that there's so much concern in healthcare among people, about reputation and about the need to maintain reputation, which ultimately is tied to trustworthiness and being trusted to do certain things that are really hard to do, and that's important.
And reputation is tied to that. I think reputation is also a crutch for many of us. To generate a sense of personal security when we're all inherently massively insecure. Frankly, I've been talking about this lately, and I just think the more that I say it out loud, the more people are like, yeah, you know, you're right.
We're all pretty damn insecure, and some of that insecurity is completely understandable. And that's just attached to the uncertainty of practicing medicine and the stakes that come with it, and the need to be right all the time, and the impossibility of that. And that just breeds some insecurity.
And then you layer on that, some of our personal insecurities, God, healthcare can really prey on those things because

[00:18:00] it is a pretty rigid system and it has a pretty rigid set of standards and ways of being. Which are often captured under professionalism. That frankly only apply to me and you as white men if you really look, if you really wanna be honest about it, that they were developed in systems and in eras that were dominated by white men.
And a lot of those professional standards still exclude the very unique, rich, diverse experiences of other people. And yet by excluding them. At the same time, demanding that they be assimilated into them. They drive a lot of pressure for people to change themselves as opposed to providing the space for them to exist in these really authentic ways, which is a very vulnerable thing to do.
There's the issue of insecurity, and a lot of that drives tribalism. I think we find our camps of people, we find our specialty that makes us feel. Worthy, likely we belong. It might make us feel better than other people. Just be honest. If you train for five more years than me as a primary care doctor in some way, I could see how you might think you're better than me at certain things.

[00:19:00] Well, you are, but you might think that fundamentally you are better than me. And that's helpful if you're feeling insecure in other ways or if you're being mistreated by other people. And so then I think we have this tendency to circle the wagons around our camp. Then other people become a threat to that, or at least they become an outsider to it.
And rather than saying, oh man, here's this family medicine doctor who's struggling with this patient and needs my help. And yeah, this is pretty easy for me, but. Not for him. Rather than giving the chance for him to feel like I'm looking down on him through my tone of voice, et cetera, I'm gonna try extra hard to make sure he feels supported.
And that then comes down to how we talk to one another, the words we say, how we express ourselves. And we have massive problems with that in healthcare. It's really shameful, frankly. The way that we treat each other, all in the course of trying to help other people. So, you know, shame is deeply embedded in all that shame itself is also a huge inhibitor to reaching out for help.
Especially when you're reaching out for help with your own

[00:20:00] shame, or your own struggles, fearing that other people are gonna see you the way you're seeing yourself, or see you as weak. And I think this is really problematic for men. I think this one really gets us bad. For sure.
Right, and in having these conversations, right, trying to normalize the experience and, I shared with you ahead of this recording that, I stumbled upon this concept of shame. I knew the word, I understood the concept and, it took me some time to figure out how it applied to me and my medical education and my life in general, and all of those things.
And about four years ago, I wrote a blog post about shame and shame in medicine. And I had written in the kind of caption of this blog post, something along the lines of. Shame is a normal human emotion, but it is not productive. And shame holds us back and prevents us from dreaming big and accomplishing our goals.

[00:21:00] And I went on to say that the world of medicine is built on shame. It's time to start tearing down some walls and creating a stronger, more resilient foundation with the attempt to open eyes and get people thinking about it. 'cause we really can't change things until we're aware of them and thinking about them.
And I got this comment, and I'll never forget it, and the comment was essentially, the world of medicine is built on science and you should be ashamed of hawking this stuff you quack, which for me was an intensely shaming experience and. There was also a part of me that felt pretty good about it.
Number one, I just got shamed on my shame post. And number two, it got somebody thinking right? And even if that other person didn't agree with me, and who knows if that person was a physician or in the medical community or what have you. But as you were describing, there are some rigid structures and hierarchies that

[00:22:00] exist that. It is uncomfortable to question. We were all, quote unquote, raised in these systems and to push back on these systems in this way where we're trying to disrupt the quote unquote norm. It's uncomfortable and shame is a tool that can be used to try and keep people from talking about it. Yeah. You know, impossible to know anything about the person that made that post, but more likely than not, that was coming from a place of some form of insecurity that you're reading about this was tapping into, and that's a classic behavior to deflect your own feelings of shame or your own awareness of your capacity for shame.
You know, Donald Nathanson is this great psychiatrist, has this amazing model called the Shame Compass, and he describes these behaviors. Through which we attempt to bypass the discomfort and the pain and the acknowledgement of shame. And one of them is attack other, right? And there's this kind of notion that if you don't transform it, you'll transfer it.
And this is where I think men can

[00:23:00] be particularly, prone because we're also just bred in a society along the way that to be. Powerful. You need to be violent or you need to be bigger, or you need to be stronger. And then that's a protection against your vulnerability. And so what you do is you put someone else down to make yourself feel better.
It's like the classic schoolyard bully. That is not A real tough guy actually. He's probably a real shame-ridden person like the rest of us, but just is intolerant of that. There are other behaviors like compensating, attacking yourself, and withdrawing.
One thing we need to cultivate the ability to do is to be able to see when shame might be. Underlying some of those behaviors so that we can attend to the shame before we just get into a war with the person and put them down and then suddenly all we're doing is just beating each other down when we really just need to be accepting each other more, or understanding or humanizing ourselves.
Shaming is a huge challenge and issue and. I think there's also a misguided notion that it's necessary, and it's necessary for creating a doctor, for example. I hear that all the

[00:24:00] time. People are just really hesitant to let go of the idea that if I don't shame you, you're not gonna be as good of a doctor.
That's a great debate and conversation to have. The other thing I just will say real quick is that when you talk about tearing down some of these pillars of healthcare, and honestly, shame is pedagogy is one of those pillars. Rather than just going out with an ax and trying to chop it down from the top.
What I really try to do is just get back to some of the fundamentals and then build from there. And one of those fundamentals is that we are all in an endeavor. We're in a profession that is ultimately for the benefit of other people. It's a humanistic profession fundamentally. So many of our behaviors and our cultures and the way we treat each other are in complete tension with that, right?
How can we shame a learner and at the same time. Profess to deeply care about them in the way that we should as learners, right? How can we shame a patient and at the same time say that we deeply care about them? If we deeply care about people, we have to care about the ways they feel

[00:25:00] about themselves as a result of our interactions with them, and if we can recognize that our interactions with them can make them feel very poorly about themselves and enact some pretty detrimental behaviors, then we have to change the way we interact with them.
Right? Let's talk about this whole shaming and teaching thing from that perspective, instead of just stop doing this. It's no good. It's a bad behavior, right? Which can sometimes provoke some pretty significant defensiveness. So I think a lot of this is, we gotta go back to basics.
It's like kindergarten stuff. Like treat each other, the way we wanna be treated and let's work from there. Yeah. Essential. Essential. And I'll offer, to the physicians listening. And this is coming from somebody who signed up for physician coaching because I needed it, right?
Like I didn't show up in my current form. Right? And so I, again, have not always been the person on the other end of the consult request that I wanted to be. And if I let that define who I am now, I never allow myself to move forward and become someone else. And so it's

[00:26:00] okay that shame has been a part of.
How we were raised in medicine and even sometimes how we have behaved in medicine. And it doesn't have to define who we are moving forward. And that's why I think that the work you're doing is so important. And so I'm curious for the physicians, do you have any suggestions or strategies that help people to recognize and move through their shame experiences?
Yeah,I'll answer that. I'm gonna make one quick point to what you made. That's really important. We have to acknowledge the systems and the nature of the work we do are make it very hard to not ever shame anybody. And especially accidentally, you know, we all have our days and we get frustrated and we do need to transfer our frustration sometimes, and even our shame.
We're just humans, and we're working in hard environments. I certainly would not want us to feel destructive shame as we recognize ourselves as shamers or having shamed,

[00:27:00] right. If we feel bad about that, we need to transition that feeling.
And this is maybe one of the strategies for managing shame across the board. If you're feeling a certain negative way about yourself as a result of a transgression, one of the better ways to move through that constructively is to try and transfer the locus of that blame off of your entire self and onto some of your actions or behaviors or tendencies or even circumstances outside of you that are modifiable.
Okay? So if I'm a person that, consciously Or not thinks that shaming people is a good way to get them to grow and learn, and I'm, and I start to realize that, ooh, that might actually be on the whole a negative. Experience for someone, a detrimental, destructive experience for someone, and I start to feel badly about myself and see myself as a shamer.
That's not how I would wanna see myself for me personally. I would get defensive about that. If I was being made to feel like you're a person who shames people, right? Oof. I would get defensive. No, I'm not. You're the problem. No, these learners, they're so sensitive today.

[00:28:00] Or just how medicine's so easy. It's not me, it's them. That's not constructive. What we need to be able to do is say, okay, I don't see myself as a shamer or. A shaming person, but I see myself as someone that's using a certain approach right now that might be ineffective. It's the approach that I'm taking.
It's the tendency I have. And that could be driven by some things about me that I need to work out, right? I grew up with trauma in my life or I was neglected. or as a young man, I dealt with my extreme vulnerability by putting up a wall of armor, and that wall of armor is just not helping me that much in this current role.
We might have to attach those behaviors to deeper things about ourselves, but the goal there is to attach them with greater understanding and awareness so that we can change the behavior, not change the person. And in so doing as we do change those behaviors, we give ourselves new ways of knowing ourselves, new ways of experiencing ourselves that.
Help us build healthier

[00:29:00] self-concepts, and then all the while we always carry with us the things that have made us feel shame forever. You can't just undo the things you do that make you feel bad about yourself. You just have to kind of develop new ways of understanding them, relating to them, and even owning them, but then compartmentalizing and learning from them so that we can be better in the future.
And that's what this is all about, man. All of us, the vast majority of us in healthcare, just wanna be better for the people in our lives. And that's another reason why we need to be maximally supportive of each other, you know, as we all do that hard work. Yeah and you bring up excellent points here, which a lot of this stuff is so embedded in how we were raised and who we are and our experiences throughout our lives, and I just wanna offer.
You don't have to, go to therapy for years and unpack all of the childhood traumas unless you want to, in order to make effective changes in who you are and how you show up at work, right? Like, there are ways of showing up differently that don't require

[00:30:00] years and years in therapy. Not disparaging therapy.
Therapy is great and you can do it if you choose to. It's not a requirement for working through. How are we showing up at work? How is shame playing a role and how can I show up as the physician and person I genuinely wanna be? I know for me, the shaming.
Response was common for me when I was feeling overwhelmed when the 20th consult of the day had rolled in and I didn't know how it was all gonna get done and I was by myself and I didn't have any help and all of those things that the more frustrated I got when the next consult rolled in and I, progressively unpleasant and.
There are ways to work through that that don't require tearing down the person on the other end of the phone. And I learned how to do that. And again, I'm not perfect at it. Right. It doesn't work out every time, but we can be better if we wanna be. Yeah. I'll build on that. And back to your earlier question about what are some things we can do to engage with shame and
this can be supported by a

[00:31:00] therapist and these are the things you can do right away. they require some work and attention, though. I'll say, a few of the things we're learning about. The ways that our brains work and what they tell us about ourselves and how we feel about ourselves that are really helping to identify some of these strategies are things like when we feel shame, we are often concluding things about ourselves, feeling things about ourselves that are based on unexamined assumptions.
Operating as facts. Okay. So in other places in psychology, these might be called cognitive distortions. But they're unexamined assumptions operating as facts. So for example, I get to the end of a brutal clinic and I'm an hour behind and I'm just hadn't written any of my notes and I'm barely hanging on.
I go around, I go into the physician workroom and I'm like, no one else would've had a hard time with this. What's wrong with me? Look at everybody else. Everybody's pretty chilling here and I'm falling apart. That is an unexamined assumption that frankly is dead wrong. Most of the time. Everyone's struggling, everybody's having a hard day, and we just are really

[00:32:00] good at hiding the struggle, right?
So there's a lot of impression management that doesn't let us see the struggle and that can then give weight to the assumption, but the assumption is unfounded. And so if we are operationalizing Unfounded assumptions, then one of the strategies is to examine those assumptions. Is that really true?
Like is it really true that I'm the only person that failed this test? Probably not. Is it really true that I'm the only one that's struggling with this? No. When we do this with working with med students, one of the things they'll say is a big barrier to feeling shame is that they feel shame about feeling shame and that they're the only one that could be feeling that way.
Then we'll do anonymous poll everywhere and we'll say, who has felt shame in the course of their education here? And it's 90 to a hundred percent of the time. So that, right there, like anytime you think you're alone and feeling this, it's false. That's not a fact, it's an assumption. So really cultivating the ability to examine those assumptions.
And there are some good strategies from CBT and other frameworks from psychology that can help. The second is to go from a place of internally oriented distress to a posture that's

[00:33:00] more externally oriented and that can take the form of just finding the courage to ask for help.
Having the people to whom you can go to ask for help, but it also could be that you try to just shift the locus of your own attention and self-centeredness, frankly, off of you and your distress and all the things that make you unworthy and bad, and onto the ways that your behaviors are affecting other people or towards people that might be.
Able to help you process through some of those thoughts, examine those assumptions. So it's going from a place of isolation and sort of rumination into one that at least opens the door for interaction with other people. And the consideration of, how are my actions affecting other people?
And then a third is just self-kindness. Self-compassion. You can't really ask that question of yourself. How might I be affecting other people? If you're not able to be kind to yourself when you answer it, because sometimes those answers really don't feel good. Oh my God, I'm neglecting the other people in my life.
I'm talking down to people.

[00:34:00] I'm, transferring my own shame to them. And then I gotta confront that, so the practice there is just treat yourself how you would treat a loved one or someone you care about. And you know, there's plenty of people that have talked about this.
You know, Kristin Neff has done some great work around self-compassion that I'd recommend, but that's a practice we've gotta be able to cultivate. And I think as physicians especially, we are often. Self-deprecating to a fault. It's like if we think if we give ourselves a pass on something, we're not gonna ultimately be able to rise to the occasion of taking care of people in high stake situations.
And I just think that's just an assumption in and of itself that is unfounded. Yeah. And to connect the dots here, right? We, belonging is so important to us fundamentally, and this feeling of shame, which threatens our connectivity to other people it's why we try to keep it hidden.
It's why we don't want to talk about it at the end of this clinic when you're like, oh, it's just me. Everybody else is doing great and why can't I keep up? And simultaneously

[00:35:00] it is in. The sharing of that experience, it is in our ability to talk through it, and we get to choose who we're speaking to, right?
Like you and I have decided to put ourselves out there into the world and talk about these things publicly and from the individual physician's experience that is not required, right? You can find a trusted friend, colleague, peer, whoever, to talk through these things with. As a, Gen Xer, when I think of shame, I think of gremlins and I think about how gremlins thrive in the darkness and you kill them with light.
And I think of shame in very much the same way shame dies when we shine light on it. And when we can shine light on these things that we're experiencing and even just have a conversation with a colleague that feels safe to us in that moment, a trusted colleague. It begins to lighten the load and the shame starts to dissipate.
And the more we can talk

[00:36:00] about it, like you and I have both shared here the experience gets easier, right? We think it's gonna be this like seismic shift when we start talking about vulnerability and shame. And then you realize like, no, I'm still the same person. I'm still a respected physician. I still show up and do my work.
And I'm healthier mentally. You might even be more respected, or at least more appreciated, as someone who's willing to pull back the curtain that other people are wanting to pull back as well. And you might facilitate an opportunity for others to do that in no other way than just modeling it.
You know? I think we do probably need to learn how to have these conversations. It's funny that even say that out loud because it's like, well, we shouldn't have to learn about something that is just fundamentally about us as people, but because of the nature of shame, it wants to bury itself.
And we want to deflect it. We do have to practice this, and we have to work at it. So some of that is just understanding how to go to someone for help. Instead of just saying if you're gonna say something to someone, I'm really struggling,

[00:37:00] which is fine. I would encourage people to think about saying, I'm really struggling with how I feel about myself right now. Like, I'm really down on myself. Okay. And so take it to that self-conscious level, not just the basic emotion level. I'm struggling, or I'm burned out, or I'm anxious, or I'm sad, but I'm down on myself, man, you know, for the person on the other end of that.
Cultivating the ability to get to that level as well. Right? If you have a colleague or a friend or something that's coming to you and they are struggling or they're exhibiting some other challenging behavior to be able to say when it's appropriate and within a trusted relationship.
Can you tell me a little bit about how you're feeling about yourself right now? Like, how do you view yourself or how do you think other people are viewing you right now? That's often an easier inroad than saying, Hey, are you feeling a lot of shame right now? That's a tough one.
Unless you're talking to me, you can come talk to me like that, but most people are gonna kind of recoil from that notion, but trying to just open up space for how they're feeling about themselves, you know? And, to Be able to answer that question, there needs to be a foundation of trust.
There needs to be an understanding or a belief that this is someone that really cares

[00:38:00] about me and also that this is someone that. Authentically wants to know the answer to this. You cannot ask that question in a token way. That can actually can be detrimental. The third thing I'll just say is that I think we also needed, we've gotta work intentionally to create environments where these types of interactions are possible.
And I was just thinking as we were talking. You know about the scenario where you go into the physician workroom at the end of the day, like you can't go in there and completely unravel the way your emotions might wanna do. You know, you cannot wear your shame on your sleeve all the time. We have to hold it together for much of the day, much of the work we do.
And so there's gotta be a middle ground. There can't just be pure stoicism and there can't be pure emotionality. We have to cultivate and carve out. Places, relationships, trust, values that give us the ability to manage these things and be stoic when it's necessary and be emotional when it's necessary.
And that's the fun part of this work is like figuring out what does that look like? And that looks different for

[00:39:00] probably every group. I'll tell you, it looks different in surgeons. I'm working with a lot of surgeons now and that's a different animal for them than it is for a group of family medicine doctors.
I think it might be different for a group of nurses versus physicians. We all have different nuanced experiences, and so we gotta figure out how do we begin applying some of these basic tenets and strategies within the really complex sort of sociocultural environments that we're in. Yeah. and just to point out a key word that you said here, this has to be cultivated.
It has to be intentional and these are not things that just happen. We can't just sit in the physician workroom and expect that these conversations are just going to happen because like it or not, that's not the culture, right? That has not been the culture. And it doesn't mean it can't be, but it does have to be cultivated and it does have to be intentional .
Well, and that just goes back to the point we made earlier, that's where we just. Recommit to and rely on some fundamental values. You know, are we gonna be an organization, a hospital, a

[00:40:00] team that fundamentally believes in the inherent worthiness of all people? Are we gonna do that?
And if we can do that, then we can begin doing a lot of these other things too. Yeah. I think the work that you're doing is incredible. I'd love for you to tell the audience a little bit more about the work that you're doing and where they can learn more about you and your work.
Thanks for the opportunity. Maybe just to share a little bit of that. I want to acknowledge my colleague in a lot of the work that I do at the Shame Lab named Luna Dolezal. So Luna is just a brilliant mind and person. She's a philosopher who's done lots of work in shame and in medicine, shame and femininity, shame and patient care.
And so anything, almost everything that we've created in the last few years has been a co-creation. And so Luna and I run the Shame Lab and we have a website, shamelab.org. It's a great place to just learn about what we're doing, read about some of our research and then we're developing and delivering training.
And that training is, built on a framework we call shame competence. And so it's a set

[00:41:00] of skills and principles and practices that we can all learn and apply within professional practice settings to engage with shame constructively, and then to, harness all of its transformative potential and doing the work we do better.
I would just maybe put a plug in for the. Shame in Medicine podcast series through the Nocturnists. The Nocturnists are some of the most brilliant creatives. in our time and they harness the power of story so beautifully. And we were able to work with them for a 10 episode series that does that with shame.
And then the last is the, we run a little consortium called The Shame Space. And it's a place where we facilitate engagement. We have some creative resources, graphic medicine, a documentary film through which to explore the concept of shame in a more sort of artistic, creative way.
And then the Shame in Healthcare Network as well. We've just formed recently, so anyone with an interest in shame it's a network that's being executed across quarterly webinars right now, but we're looking to grow it. and so, be happy for you to reach out to me or through either of those websites and we can get you

[00:42:00] enrolled in the network.
Thanks for the chance to share. Of course. Absolutely. And another plug for the nocturnists arc on Shame in Medicine. That was where I first heard you speak on this, and it really opened my eyes to so many aspects of how shame shows up in medicine and in healthcare at large. So if you haven't listened to it, highly recommend.
Dr. Will Bynum, thank you so much for being here. To all the listeners, thank you so much for spending some time with us. Today and we'll see you next time on the Better Physician Life Podcast. Take care.