Insecurity and shame at work

She had me in her terrifying grip, and I was paralyzed.  Stuck to my chair, my heart racing, instantly isolated in my desperate confusion.  I heard ordinary sounds like two nurses chatting, papers shuffling, and a telephone ring, but they seemed distant, happening in some safe place far away beyond the dark tunnel I was now in.  No warning.  She had asked me a series of questions, and all seemed to be well until suddenly I felt trapped, clamoring for an answer I could not call to mind.  How could a typical day during my internal medicine rotation as a third-year medical student shift to one of the most humiliating experiences of my life in a matter of seconds?

“Give me another explanation.”  Another explanation?  I had run through my differential for hypocalcemia, and I was drawing a complete blank.  I was two days into a new clinical rotation, and I didn’t know this preceptor very well.  At first, I thought our conversation would be reasonable, even possibly a friendly back-and-forth.  How could I have been so wrong?  I quickly reviewed all I had offered; vitamin D deficiency, hypoparathyroidism, renal dysfunction, liver disease, drugs…To this day, I can’t remember if I offered more reasons, but I do clearly remember I was not giving her the answer she wanted.  So she waited, and waited, and waited.  I would have been happy to discuss all the reasons I was forgetting, but that seemed not to be the point.  The back of my neck became hot; my palms were damp, my hesitant voice softer with a tremble.  And still, I was not being released.  She continued to wait and stare and fix me to this spot at the desk.  My eyes were on the patient’s medical chart we were discussing, and her eyes were on me.

“You can’t think of another reason?”  I got really quiet.  “It is the most important reason for a low calcium in a patient.  If you don’t know the most important reason, you could cause serious harm.” – her voice escalating and accusing and driving intimidation and fear.  But I didn’t know.  I didn’t know the answer she wanted, and I was spiraling, self-doubt, criticism, shame – I told myself I didn’t know because I was stupid, and long before she let me off the hook, the damage was done.

“Lab error,” she said.  “The low calcium might be a lab error.”

Right.  Yes.  Only one conclusion to draw, and I had drawn it.  The rest of that morning, I struggled to stay in the room.  The very best parts of me had floated all away.  My compassion, sense of humor, and confidence – all the things I know make great doctors were fading, and I was left with shame.

Shame still shows up in this profession.  I have been practicing emergency and hospitalist medicine for 18 years, and I am so sad about all the shame experiences I see happen at work.

I remembered years ago, a seasoned anesthesia consultant rushing down to the emergency department in between surgical cases, asking for the ‘new doctor who thinks I have time to waste.”  This had followed a hesitant request for help with a difficult lumbar puncture.  I had overheard some of the telephone conversations and had cringed knowing this newer physician was probably stepping on a land-mine, given this consultant’s reputation.  I had feared it might end badly, but I was so embarrassed for this mindless tearing down.

Doctors are good at inflicting psychological harm upon each other because we are all insecure.  No one is perfect, but it is hard for doctors to come to terms with that.  We are high-achievers at the top of our game, where the stakes are high.  We need to be perfect because if we make mistakes, people can die.  And yet, secretly, we are aware of our short-comings, so we do ugly compensating things to feel better about ourselves.  We all struggle with self-doubt, but we will never admit it.  We self-soothe by shaming each other, and we justify our crippling behavior by calling it “professional feed-back” or “an opportunity for growth.”  We know better but hurt people hurt people, and we were all learners once.  We all have stories of how we were shamed.

When we kick our peer down the hill, we get to stay on top, and that feels a lot better than admitting we make mistakes.  It’s survival.  It’s the bully in the schoolyard, and it is ugly.

But I have also seen the remedy in action, and that gives me hope.  What you say and do at work can help break the shame cycle.

Three simple behaviors to adopt and applaud your peers when you witness them at work:

1. Elevate others.  I complimented an ER physician the other day when I saw that he had picked up a squamous cell carcinoma that presented as an unusual looking scratch.  Without skipping a beat, he said, “Oh, the nurse who’s on today works part-time in the plastic surgery clinic – she picked it up right away.  I am not sure I would have diagnosed it that fast without her help.”  Fantastic.  Congratulations passed along in order to lift up another.  It warmed my heart.

2. Offer to help.  I was finishing up a particularly brutal night shift and scrambling to hand over a complicated patient in the middle of a workup.  My colleague saw I was spent and stopped me mid-sentence.  “Let me take this off your hands.  I’m happy to review the chart and make sure you didn’t miss anything.  Can I do that for you?”  Relief, a small burden lifted – so grateful for him.

3. Believe the best and show respect.  Team rounds started at 8 a.m., and one of our new residents was late.  I knew he had been late twice the week before, and it was a bit annoying.  Our chief spoke up and said, “I’m sure he’ll be here soon. It’s probably traffic.  He’s doing so great with this rotation.”  Some grace and an unsolicited compliment.  Wonderful.  And when he arrived in the next five minutes, my colleague closest to the door offered him her chair.

Shame is a monster, and it can destroy us, but we have the tools to beat it back and conquer it in ourselves and in each other.  It’s time to look for all the ways we can succeed.  I believe we can.

Rose Zacharias is an emergency physician.

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