Shame and the medical profession [PODCAST]

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“We can’t escape shame. But don’t despair, dear reader, because shame resilience can be cultivated. There are mental-fitness skills that can be learned which are self-perpetuating. I taught myself these skills and, in doing so, healed my own wounds – you can, too. Once you have the skills to recognize and manage shame in a healthy way, you’ll no longer be held hostage by the perceived need to betray yourself by pretending to be someone other than who you are. An enormous weight is lifted, and the world feels safer when viewed through a lens of self-trust.

There’s no better investment you can make in yourself.”

Tracey O’Connell is a radiologist and physician coach. She can be reached at her self-titled site, Tracey O’Connell, M.D.

She shares her story and discusses her KevinMD article, “Why we deny our imperfections in medicine.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back on the show Tracey O’Connell. She’s a radiologist and physician coach, and she recently wrote the KevinMD article “Why we deny our imperfections in medicine.” Tracey, welcome back to the show.

Tracey O’Connell: It’s always good to see you, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but for those who didn’t listen to our first conversation, can you just briefly share your story and journey to where you are today?

Tracey O’Connell: Sure. And I’ve revised or updated it a little bit, just to go into a little more detail that I feel is relevant to the topic today, which is that I had gone to medical school to be a psychiatrist, and then I had some early training experiences that made me feel like that wouldn’t be a good move for myself. One of them happened within the first month of medical school. Because I had expressed an interest in psychiatry, I was grouped with several others with the same interest in a small group; all of us had been arranged according to areas of interest. And we were placed with a really well-revered psychiatrist at my institution. He was charismatic, and he lectured to the medical students about psychiatry, and he was very warm and shared a lot of stories, and so we let our guard down in that atmosphere with regard to what was happening.

He asked a lot of probing questions, like, “What is your adjustment to medical school doing for you? How are you feeling? How are you adjusting? How are you coping?” And because I felt safe in that environment, I told exactly how I was feeling: that I was feeling overwhelmed, that I felt inadequate, that I felt completely inept at managing the volume of reading. I had never been much of a reader, and as a psychology major, I really struggled with some of the science, especially biochemistry and things. And so I ended up being very vulnerable in that setting. Sometimes I would cry and have to go outside. He would say, “Let’s go into the hall and have a conversation about this.” And I felt safe. I felt like that was appropriate.

But at the end of the course, when we got our evaluations, the only thing that he wrote on my evaluation was “seemed younger than the rest of the group.” And while we could interpret that many ways, I interpreted it to mean that I was emotionally immature or didn’t have what it takes to be a doctor. And if a well-respected psychiatrist in a small group setting did not feel that I had what it takes, I was really in trouble. And so it changed the trajectory of my entire career, because I thought, “My emotions aren’t safe. They can’t be trusted. I need to be a lot more knowledgeable, a lot more guarded, and kind of shut down a part of myself in order to be able to do this work.”

And so, yeah, I ended up becoming a radiologist, thinking that that would be the furthest away from patient contact and emotional experiences. But unfortunately, or fortunately now, my feelings came with me, and it has maybe been more in alignment with who I really am to have done all the work I did to manage myself during those years when I was living in opposition to my real self, my real, authentic, vulnerable, raw self.

Kevin Pho: Now that you’ve had time to reflect on that experience, and you’ve gone through radiology training, and now you’re a physician coach, if you were to do it again as a medical student, would you have left yourself so vulnerable if that situation reoccurred?

Tracey O’Connell: Well, obviously I wish that I had had a stronger sense of self at that time. Many of us enter medical school when we’re really young, and we’ve been focused on the achievements, the criteria, the checklist of how we’re going to get in, and on the struggle and the anxiety of “Am I good enough?” And I know now that for many, and most, that doesn’t really leave. But at the time, because no one was talking about it, I felt very exceptional in that way.

And so it’s interesting, because when I look back on my younger self, I don’t think I did anything wrong. I don’t think I made a mistake in trusting that environment. And I actually recently spoke with some of the people who were in that group with me, revisiting that incident with them and finding out, “What was that like for you? How did you feel that setting was?” and sharing my story with them. And also, that professor recently passed away, and many of us were talking about the impact and what an amazing person he was, and how it certainly was never on his radar. Who knows what was really meant by that comment, right? It could have meant I actually was the youngest person in the group. I really was, by age. But I never knew. There wasn’t any explanation. And so I think it would have changed the trajectory, but the reality was that the struggle I was having probably would have manifested in a lot of ways anyway, as I was developing as a human being side by side in the midst of medical culture.

Kevin Pho: So you talk more about the concept of vulnerability in your most recent KevinMD piece, and it’s titled “Why we deny our imperfections in medicine.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share a story of why you decided to write it?

Tracey O’Connell: Yes. Well, the title is ironic because it’s a little bit benign. The reality is the article is about shame, and about shame in medical culture. And because of all the research I’ve done, and all the studying of Brene Brown’s work and all the other literature around emotional intelligence, I know that people don’t want to talk about shame. So I didn’t put shame in the title, because I thought that would immediately turn people off. And maybe that was a mistake, because I think there are people who are willing to use the word shame and know that that’s exactly what they’re feeling. In retrospect, putting shame in the title might have been a wiser choice, because the article is about shame, because the reason that we’re not honest about our imperfections is that no one taught us how to cope with feeling bad about ourselves.

In the beginning of the article, I describe, and I’m reading here, “In her book Daring Greatly, Brene Brown says, ‘If we want to be fully engaged, to be connected, we have to be vulnerable. In order to be vulnerable, we need to develop resilience to shame.’ And so if you’re a physician who’s not good at being vulnerable, it’s likely you’re steeped in shame, and you’ll never be able to admit it.”

And so I think that it is something we need to talk about. Because I’ve done all this work, I’m comfortable, very comfortable, talking about shame, and yet I struggle to make it palatable for those who aren’t ready to step into that and what that means to them. And I think it has huge costs, and I believe that’s a huge part of the burnout rate and suicide rate, which goes without saying, really.

Kevin Pho: Can you share some hypothetical or even real-life scenarios where physicians or even medical students would encounter shame just as part of their daily work life?

Tracey O’Connell: The reality is that we often are our own worst critics, right? So we’re kind of shaming ourselves all day long: when we’re behind on our charting, or, for me as a radiologist, when the list is getting really long, or when I make a mistake and my colleagues call it out or a referrer calls it out. And it’s busy. The workload is busy. There’s not time for adequate processing or deconstructing, or even taking that and questioning the story, like, “Is it really wrong? Did I really make a mistake? Or do you just disagree with me?” That was a huge source of shame for me in my career as a radiologist, because there was a lot of competition among my colleagues.

And I later found an incredible document, which I’ve saved, which was in a Lippincott Contemporary Diagnostic Radiology, sort of a CME activity, that documented how often there are different interpretations, say, in radiology. I do musculoskeletal imaging, so say regarding the rotator cuff or the labrum, there’s so much discrepancy on what’s really happening, and you can go down the hall and talk to seven different radiologists and get a different interpretation, as well as seven different orthopedists. And so I think that for many years, I was told that I was wrong, and I’ve since met up with people in community settings who have said, “Yeah, that’s ridiculous. We never know till we go in there.” And this Contemporary Diagnostic Radiology article had documented that 82 percent of the time there will be inter-observer variability within musculoskeletal imaging alone, and they had different statistics for different areas of radiology. But if I had known that then, I wouldn’t have been so hung up on “Why does everyone think I’m doing it wrong? What can I possibly do to get better?”

And so, yeah, I was steeped in feeling like I’m not enough. And I think that’s the euphemism for shame. People can relate to saying, “I don’t feel like I’m enough. I’m not young enough, thin enough, smart enough,” all the time. And those are messages of shame, and recognizing them as such gives us a vocabulary that we can work with to address it.

Kevin Pho: So let’s say a physician or a medical professional experiences an event that leads to shame. A lot of physicians are taught, like you said before, to keep it in, to be stoic about it. Now, what are some other ways that physicians can deal with those feelings of shame that would be more constructive?

Tracey O’Connell: Right. So I think, as we all know, we aren’t given the tools, the emotional intelligence tools or even social intelligence, to be tuning in. We so overdevelop, if this is the mind, right, we so overdevelop our intellectual brain for facts and figures and data and the latest research and the protocol, and it really congests the part of the brain that’s really wise and full of a lot of intuitive understanding and tuning into our own selves. So of course, I’m an idealist, but I also am very practical and want to reform things, and so I can talk on a global scale about what should be done in medical culture, within medical school, as far as giving people these tools.

And I have a ton of actual work I do with clients to go over, like, what is the physiology of shame? How does shame show up for you? Where do you feel it? Is it in your chest? Is it in your throat? Is it in your abdomen? Are you holding tension in your shoulders and your throat? And recognizing it: “Oh, I’m feeling this,” right? Shame is this intensely painful belief that we are inherently flawed and not worthy of love or belonging. So when we speak to ourselves, because in medicine we are setting such high standards, standards that are really ridiculous, they’re not achievable. An ideal is, by definition, just out of reach, right? It’s not within reach. So anytime we fall short of our ideal identity, or are perceived as we do not want to be seen, in an unwanted identity, then we’re cast into shame. We’re cast into this place where “I don’t belong. I’m not good enough,” or “I’m being seen as how I absolutely do not want to be seen.” Regardless of what your personality is, we all feel a protective need to care for self.

And so I think that, and I’m not sure if I’m getting off on a tangent from your original question, but I found for myself that the way to address my shame was to really recognize that’s what I was feeling, first and foremost, and admit it. Admit it first, like, own it, claim it, and know that these sources of shame may not go away. Shame is universal. It’s not just within medicine. It’s universal to all humans of all skin, ethnicity, and location on the globe. And yet we can do a lot with recognizing what our shame triggers are, doing the best we can to avoid them when possible, but then also knowing and building up shame resilience, which I touch on in this article.

But that’s really what I work on individually with people: recognizing your shame triggers, and then, when you are in shame, what do you do? Do you move away, get quiet, seclude yourself from others, hide? Do you move toward, like people-pleasing and trying to work harder, achieve more, apologize, fix it? Or do you move against, and become aggressive and intolerant and defensive and bristled at anyone else’s vulnerabilities? And so we see all these personalities manifest in medicine, and I think it’s helpful to have the tools to recognize that that’s what’s going on in yourself and also in your colleagues: that so much of our own stories are personal, and many of our interactions with others are not. They’re really based on the story that’s happening inside of that other person.

Kevin Pho: We’re talking to Tracey O’Connell. She’s a radiologist and a physician coach. She wrote the KevinMD article “Why we deny our imperfections in medicine.” Tracey, one of the things that you said is that once a clinician feels feelings of shame, they certainly have to recognize it and validate it. And then you did mention some tools that are available that they can use to help address the issue of shame, and it sounds like a lot of these tools are certainly individualized based on that clinician’s personality and situation. But in general, short of individualized coaching or an individualized session, are there any actionable global tips that you could share with the physicians who may be listening to this podcast on how they could deal with feelings of shame once they recognize it?

Tracey O’Connell: Yes. So when you recognize that you’re in it, when you notice you’ve been triggered and you’re feeling a physiological response that’s uncomfortable, and you recognize your internal message is “I’m not enough,” then the first and foremost thing is to ask for help. And then people say, “Well, who am I supposed to ask? Where am I supposed to go? I can’t let my colleagues know.” And I know peer support is tremendously important and helpful, and yet some of us don’t even feel safe sharing those things with our colleagues.

So it’s really important to kind of do a thorough. There’s an exercise I do: You take a one-by-one-inch square on a piece of paper. Literally get a ruler and put a square, an inch-by-inch square, and in that box, put down the names of the people whose opinion really matters to you. And ideally, you put yourself in there. Ideally, you put yourself, how you view yourself, how you regard yourself, how you respect yourself; that matters, right? And what’s interesting is people do that exercise, and they are either shocked, because they’re upset they can’t fit all the people whose opinions matter in that one-by-one-inch square, or they realize, “Wow, I’m spending so much time trying to control perception, and so much of my messaging is coming from sources whose opinions don’t really matter to me.” So that is a really helpful exercise that we can all do independent of another, to do on our own.

And also think about who the people are. Once you’ve figured out who’s in that box, a lot of it’s going to be who is going to give you the empathetic response that you need, meaning who’s going to be able to listen without judgment and be able to respect your experience. And you don’t need a whole lot of them. We would love to have everyone understand us; that’s a human desire. And yet we really only need a few. And if you have that person in that square box, a few people, and you’ve worked on trusting yourself, then that’s a huge skill that helps you navigate through the inevitable shame storms that we all have.

And that’s that self-compassion piece of being able to own your story and look at what’s behind the curtain, and what you’re afraid to approach, or what keeps revisiting in all these sinister ways, those stories that are on repeat, and kind of getting past that, getting to the source of: Is that story even true? Do I know it’s true? Is it a fact, or is it my opinion, my feeling, my sense?

And then lastly, by telling our stories. We have to share our stories, and there are forums for that. I’ve just recently learned of a forum in San Francisco called the Nocturnists, who are physicians who are really working toward a platform where physicians can share their stories, whether anonymously or comfortably and openly. And just to remind folks that a sizable paycheck is not a cure for shame. We have to do the work anyway, because repressed emotion just festers. It doesn’t just go away, and it can accompany us to the grave. So in that regard, maybe no one will ever know, but we’re having a crisis of the soul, a crisis of spirituality, in medicine right now, and I think it’s important to get deep and go there and recover.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Tracey O’Connell: You’re normal. Shame is not a sin. Shame is not a crime. It’s actually when we can get comfortable with the idea of shame and its existence. Shame is the main reason that people don’t want to be vulnerable, because they don’t want to feel shame. And so if you can get comfortable with it and be less fearful, stick your toe in the edge of the water of it, and realize, “Wow, I can get through this. I can survive this. It actually feels better than carrying this burden on my back,” then it makes you less afraid to be vulnerable, because the worst-case scenario, you’ve already got a plan for, just like we plan for in medicine all the time: What’s the worst-case scenario? What’s the outcome we don’t want? If we can be comfortable with “Hey, I’m going to go there, because I’ve got some tools and skills and things to fall back on, so it won’t be so scary,” then the rich rewards of vulnerability, of connection, joy, real bonding with people, real, human, deep, beautiful experiences are available. So there are incentives in doing so, rewarding incentives.

Kevin Pho: Tracey, thank you so much for coming back on our show, and thanks again for your time and insight.

Tracey O’Connell: Thank you so much for the opportunity, Kevin.

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