Shame in Medicine: The Lost Forest
A doctor flinches in the bright light. Her shoulders slump, her face is flushed, her eyes are downcast. She is experiencing confusion, disorientation. She is not ill. She is remembering. There was a test, the test, Step 1, the first part of the U.S. Medical Licensing Exam (colloquially known as “The Boards”). She failed, by a slim margin. But in her mind the failure was so momentous that she hid it from colleagues and friends.
Years later, after she has passed the test and earned her position as a doctor, in moments of reflection upon even a minor error, one with no grave consequences, self-doubt gnaws at her. Despite the test being obsolete in the face of her accomplishments, the shame of that failure comes roaring back.
In The Nocturnists’ beautifully-rendered podcast series, Shame in Medicine: The Lost Forest, they unearth a beast of an affliction. The raw, firsthand accounts by medical professionals who have endured the insidious hallmarks of shame are tenderly insightful.
The deft placement of shame within the contexts of psychology and history makes the stories all the more affecting. Hippocrates (c. 460 — c. 370 BCE) the Greek physician known as the ‘father of medicine,’ makes a character appearance, citing the requisite qualities of a successful (ancient) physician:
Clean appearance, using a sweet-smelling scent
Quiet, self controlled, in all aspects of life
Character must be that of a gentlemen
In facial expression, he must be controlled, but not grim
Then, a recent list is relayed, of the qualities of today’s perfect surgery student:
Never whines
Never complains
Is never hungry, thirsty or tired
Places his head to the ground, and hammers through any obstacles to get the job done, and then asks for more work
Hippocrates’ posh-ancient accent is funny, and they are tongue-in-cheek about it — they can be — the point is clear. The profession’s imperatives, after two thousand years, remain stubbornly intact.
The ten-part documentary is produced and hosted by Emily Silverman, MD, an internal medicine physician at UCSF, and co-produced by Professor Luna Dolezal from the University of Exeter and Dr. Will Bynum, a Raleigh-based family medicine physician practicing and teaching at the Duke University School of Medicine. Their stated goal was to create a cathartic forum wherein clinicians could share their shame experiences, gain shared vocabulary and tools to manage their reactions, and build a healthy community to which they can belong. In Professor Dolezal’s words:
“Despite the destructive effect that shame is having among clinicians, almost no research or public storytelling exists about shame in healthcare. Without understanding how shame manifests in medical culture, we cannot address or heal from the harm it causes.”
Dr. Silverman, too, speaks with great compassion about the interviewees, of seeing herself mirrored in the stories, of her respect for her fellow physicians: “I see how much we truly care about our patients.”
Shame is an astonishing, debilitating phenomenon. Concealed. Contagious. Primitive. The environment in which it lives is littered with junk food, loneliness, sleepless nights. It festers amidst other devastating emotions — helplessness when you can’t possibly provide patients what they need (stable housing, better health insurance), or grief over seemingly senseless deaths (a mother of two, with breast cancer, in hospice). When shame plus these emotions are tamped down to accommodate a relentless schedule, they emerge later, and by then, who has the time to stop and witness them?
“I don’t think I emerged like a phoenix out of the ashes. I feel like I just crawled out on my arms, and my knees, and had to slowly rebuild myself…”
To become a medical professional, you can know you are fallible, and learn from mistakes, but you must also believe that you are going to do things as close to perfectly as is humanly possible. Peoples’ lives depend on it. To believe otherwise would be apostasy, in direct opposition to the earned accolades of an institution that exists because of its employees’ truly incredible knowledge, diligence, and earned expertise.
We patients are complicit, part of the problem, too, clamoring for reassurance when we are hurt or sick. We request to be seen by a savior of sorts, and have set up a tidy network of beliefs within which they can exist as such. When facing the sheer terror of a mortal wound, we will go to the emergency room, where we hope to promptly be saved. We need to believe this, to maintain our sanity in a moment of adrenaline and fear.
The Gallup Honesty and Ethics poll has been in existence since 1976, and conducted annually since 1990. For almost the entirety of its polling era, nurses have ranked as “#1 most trustworthy professionals” (the one exception was after 9/11/2001, when firefighters took the lead). For context, the other three hovering at the top of the list as “highly ethical” were pharmacists (58%), high school teachers (53%), and police officers (50%). (Telemarketers and Members of Congress both received 25% votes for “very low”.)¹
We are not entirely wrong to feel this way about the medical profession. They do help, they do save lives. But the pressure our beliefs put upon them, relentlessly, is one site of origin for the problem. How did we as a society create this sacrosanct environment? We believe in science, medicine, discoveries, regulations, tests, laboratories. We put our trust in them, and a select group of hard-working humans do their best to uphold it.
Hubris is also discussed. There is some ego involved in a medical professional accepting the onus of perfection. Tricky. How can being responsible for other peoples’ lives not require it? The stress is tremendous, for the very same reason. As a teenager, I had a friend whose father was a pediatric surgeon, and when things did not go well (even through no fault of his own) for a child on the operating table, he would come home to sit down for dinner with his family, but not before going into the backyard to sob uncontrollably, trying to let go. How could you dare to think you could ever be perfect? Because the system we all co-created asked you to. Humans in a feedback loop.
This type of system can tend toward reductionism, and racist and classist assumptions add to the stress. “Failing while black” is a known term to those trying to rise up the ranks. In one metaphor, a participant talks of there being “a train ticket” needed to get into the medical profession. You spend so much time and energy getting the ticket. As you wait on the platform, you notice the others waiting. Some have gilded luggage carried by butlers, some have nothing but the shirt on their backs (childhood education, hopes, desires, flaws). Privilege presents an impediment, right out of the gate. In another episode, a physician recalled an instance where a professional mentor classified him as a number, rather than a person, indicating that his 3.1 GPA meant he would be screened out at every medical school, and would never be a doctor.
“I felt like a barcode, much like the barcodes that you scan at a Walmart to determine the value of the product you’re hoping to purchase…Nowhere on that barcode did it say that early in my graduate studies, I was diagnosed with cancer…that I am an immigrant, someone who was able to adjust to a new culture thousands of miles away from home…nowhere on that barcode was my humanity considered, or my potential to help others.”
The culture of shaming has an absurdly long history. Shackles and pillories were the favored machines of shame of the medieval era. Human branding was firmly established by King Edward VI of England under his 1547 Statute of Vagabonds, which specified the burning of the letter “F” for “fraymaker” on the cheek of any church brawler. Hester Prynne’s “A” for adultery was sewn on just a few centuries later, with a host of punitive examples in between. The use of shame as a teaching tactic for the masses is fraught with risk, though. Some can use it as a learning experience, and develop resilience, but others internalize a deeply-rooted shame that impairs their ability to respond to challenges that would seem insignificant to an onlooker.
The questions asked throughout the series have an eye toward being of help, in the end. The series producers hope to turn this research about shame into productive change — perhaps people could be trained to identify and respond to shame? But then, this training would imply that there are novices and experts on shame. A more inclusive framing is suggested, and enforced by the success of the series itself — everyone can be an expert, not via training, but via empathy, and by drawing on and sharing their own experiences as humans.
The Nocturnists has earned its accolades: it has been nominated for “Best Indie Podcast” in the Ambie Awards, and this shame series won a Sharp Index Award for Media Leadership. Their thoughtfulness is a through line. They followed up with personal phone calls to those who had told their stories: “How are you feeling about your story being included in the series? Did the act of sharing the story impact you in any way?”
One participant offered a telling account. “I just started talking, and then this fully-formed analysis came out — and you know the weird thing is… I didn’t know it was in there…it was twenty years of processing…I have a theory about storytelling and healing…it’s not a story until it’s healed…trauma can always be metabolized into something more beautiful.”
¹ https://nurse.org/articles/nursing-ranked-most-honest-profession/
