“I need you to forgive yourself”: Shame in Medicine and Medical Education

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On this episode of the Academic Medicine Podcast, guests Will Bynum, MD, Lara Varpio, PhD, and Ashley Adams, MD, join Toni Gallo and former Academic Medicine editor-in-chief David Sklar, MD, to discuss shame in medicine and medical education, what it is and how it can be studied, and their research and other work in this area.

This episode was originally released in August 2019 and is available through Apple Podcasts, Spotify, and anywhere podcasts are available.

A transcript of this episode is below.

Read the articles discussed in this episode: 

Disclaimer: The views expressed in this episode are the authors’ own and do not necessarily represent those of the U.S. Department of Defense, the U.S. Government, or its agencies. 

Transcript

Toni:                    This week I’m reposting an episode with a discussion Dr. David Sklar, Academic Medicine’s former editor-in-chief, and I had with Drs. Will Bynum, Lara Varpio, and Ashley Adams, back in August of 2019. Will, Lara, and Ashley joined the podcast to discuss shame in medicine and medical education, what it is and how it can be studied, their own personal experiences with shame, and their growing research and other work in this area. I’m sharing this conversation again as a lead in to next week’s episode. Will returns to the podcast with his colleague Dr. Joe Jackson to give us on update on their shame research program, including some recently published work regarding the nature of shame experiences in medical students. They also preview new research they’re doing with premedical students, that has implications for how we understand shame at different points in the learning continuum. Be sure to check back next Monday for this conversation. With that, here’s “I need you to forgive yourself”: Shame in Medicine and Medical Education, which was originally released in August of 2019. Thanks for listening.

Toni:                    Welcome to the Academic Medicine Podcast. I’m Toni Gallo, a staff editor with the Journal. Joining me and editor-in-chief David Sklar to discuss shame in medicine and medical education, and their research and other work in this area, are Will Bynum, an assistant professor in the department of family medicine and community health at Duke University School of Medicine; Lara Varpio, a professor of medicine and associate director of research for the health professions education graduate program, at the Uniformed Services University of the Health Sciences; and Ashley Adams, a first year resident in pediatrics, adult psychiatry, and child and adolescent psychiatry at Alpert Medical School of Brown University. Thank you all for joining us today.

Lara:                    Pleasure to be here.

Toni:                    So Will, I thought we could start with you. Could you just explain the difference between shame and guilt or other emotions that we might experience when we make a mistake?

Will:                     Sure thing, and thanks so much for having me, and also to you and David and all the folks at Academic Medicine and the AAMC for an incredible amount of support for this work and this topic over the years. The psychology literature has very well, clearly laid out definitions of shame and related emotions that fall under a class of emotions called the self-conscious emotions. And in order for a self-conscious emotion to occur, a person has to be engaging in a self evaluation.

Will:                     And the model that we have used to sort of frame our work, and one of the leading models to differentiate these emotions is Tracy and Robins model of self-conscious emotions. And like other leading theories, their model delineates them based on the person versus the action or behavior. And in their model, something happens. A triggering event or a circumstance or a situation that causes a person to look inward and to engage in a self-evaluation. And as part of this evaluation, they activate representations of themselves. Their current representations or how they view themselves right now in the moment in light of this event, and in their long-term or ideal self-representations, or how they view themselves in the future, the person they’re striving to become or the person and how he or she would have ideally acted in that situation.

Will:                     And then the person makes an appraisal between those two self-representations and it determines if they’re congruent. If they’ve done something that brings them closer to their ideal self, they feel pride, and this makes sense. We’ve all felt that at one time or another. If they do something that takes them farther away, that causes them to view themselves as more distant from their ideal self or who they’re trying to become, they feel either shame or guilt. And that distance of who I am now, how I’m viewing myself and who I want to be, does not feel good. So both shame and guilt are negative emotions, but there’s a final attribution that differentiates them and it’s very important. And the person decides on what do I blame this event or circumstance.

Will:                     Do I blame it on something global and stable and difficult to change about myself? If so, that’s shame. Or do I blame it on something specific, action-based, unstable and easily changeable? And if so, that’s guilt. So a person who feels shame is engaging in a negative global assessment of the self, whereas the person feeling guilt is engaging in a negative assessment of an action or a behavior. So people who feel shame say things like, “I am bad. I am flawed. I am unworthy. I am deficient. I’m not blank enough. Smart enough, talented enough, hard-working enough.” Whereas the person feeling guilt will say, “I’m not necessarily bad, but I did a bad thing. I need to fix this thing, but I don’t need to change something global about myself.”

Will:                     And we can talk a little bit more about the different outcomes and behaviors that follow from shame and guilt, but generally speaking shame is a more destructive emotion, an anti-engagement emotion and one that causes a lot of hiding and withdrawal, whereas guilt is a more pro-engagement proactive emotion that triggers attempts to grow and repair and heal.

David:                 Thanks a lot, Will. I’m wondering whether you had some experiences that you could share that kind of moved you down this road to be interested in studying it and its impact on education and on students in residence and so on. I don’t want to force you to talk about it, but if you have some experience maybe that kind of got you going down this road, I think it might be helpful for people to hear about it.

Will:                     Absolutely. This work started from a very personal place. I had two experiences very close to one another that led me to the construct of shame. When they occurred, I had no idea what I was experiencing and it was scary as a result. The first was a personal experience, getting out of a bad relationship, essentially where I came out of the relationship with deep-seated questions about myself and my self worth that had persisted throughout. And coming out of it cause me to realize that I really lost sight of myself and had gotten down on myself in global ways as a result of that, and that was a very disorienting place to be.

Will:                     So as I healed from that and really engaged in what was a lot of hard work to figure that out, I came across Brené Brown. And that was around the time that her Ted Talk was really taking off, and it was truly a game changer for me, because it put a name to the experience in such an authentic and at times humorous way, and it let me feel like I wasn’t abnormal for feeling this and that it was a challenging emotion.

Will:                     Around the same time, I was a second year family medicine resident, and I made my first major medical error, what felt like a significant error at the time, on the labor and delivery unit. I was delivering a baby who was having a placental abruption. It was my second vacuum assist delivery ever. It was a chaotic scene. I was extremely tired, and I delivered the baby but caused a very severe vaginal laceration, so severe that it was one of those events where everyone in the room instantly knew that something had really gone wrong.

Will:                     And I had the immediate feeling of standing under just a big flood light, extremely exposed and an intense desire to hide, and I kind of escaped the room. And the aftermath of that was it was a really dark place frankly and scary, because I hadn’t felt this in medicine, and it was filled with thoughts of, “I don’t belong here. I’m an imposter. I hurt people. I’m not a good person. I’m not a good caregiver and I will never be.” And a lot of fear and anxiety. I eventually recovered from that, but coming into this understanding of shame and what it is and recognizing how little it’s talked about really empowered me to learn more. And the work started from there.

David:                 Maybe we could bring in Ashley at this point, because I’m sure that you’re a little bit closer to having been in medical school and now as an early resident there are probably issues that have come up for you. Have you experienced anything like what Will is describing and would you be willing to talk about that with us?

Ashley:                Absolutely. So I think when I think about sort of the emotions and the thoughts that Dr. Bynum just mentioned and shared, you know, as a medical student I think one of the differences, a huge difference between being a medical student and a resident, is the potential for making true medical errors in residency that you don’t have as the medical student. But I think that a very similar feeling as a medical student, in terms of the emotional shame, can come even just in the preclinical classroom years where you find yourself surrounded by some of the smartest people, people who inspire you with the stories of what they’ve done to get into medical school and their ambition, and you, at least in my personal experience, I know that I felt a very strong sense of questioning and doubt in terms of my belonging, my sense of belonging within that community.

Ashley:                And I remember sitting in the classroom, whether it be a lecture or a small to medium sized breakout session and just looking around and really just focusing not on the content that I was supposed to be learning in that moment, but questioning my ability to hold up and do this work that in the way and to the ability that I felt like my peers could. So it was a lot of self comparison. Any time I didn’t know an answer or I answered a question wrong, that would be the focus, as opposed to saying to myself, “Okay I can learn from this and this is where I’m supposed to be at this point.”

Ashley:                And I think as I moved on throughout my four years of medical school, the biggest point of growth that I had was in my ability to recognize when I was having those thoughts, and having what Dr. Bynum references as a shame spiral, and really just prompting myself to pull myself out of that, whether that was by talking with other medical students or a mentor to sort of check myself back into the reality of the situation.

David:                 Ashley, this is really good. And I wonder if, did any of your colleagues or professors, faculty, either contribute in a positive or a negative way to your emotions, as far as shame and feeling like you didn’t belong? Can you think of any things that happened that kind of pushed you in one direction or the other?

Ashley:                Absolutely. I can’t think of anybody or any situation where a single individual prompted me to feel more shame. I do think that it was pretty internal. I think there’s a lot of research being done that I find pretty fascinating about the personal factors that may lead someone to feel more shame in a medical learning environment or any learning environment.

Ashley:                I think for me a moment where I realized what was happening and realized that somebody else was having these same emotions was so transformative. Towards the end of my first year, I had a conversation with a dear friend of mine, colleague Claire Edelman, Dr. Claire Edelman actually, who just started residency in OBGYN at the University of Indiana. She has worked with Dr. Bynum and I a good amount on some of the seminars and the research that we’ve been able to do on this topic. And I had a conversation with her towards the end of my first year where we just shared our feeling of wow, nobody else is talking about this.

Ashley:                And we sort of identified in one another that there was someone else out there who’s having these feelings of self doubt and shame and concern about our ability to continue this work and to make it through medical school. That conversation stuck out in both of our minds so well that it actually came up again in conversation almost a year later when we started to work formally on this topic. And we both credit that moment and just a quick conversation and acknowledgement as being a moment where we’ve really started to realize that we weren’t alone in this.

David:                 I think that’s really helpful. There has certainly been a lot of at least recognition that sometimes, in either the clinical environment or in the classroom, that teachers, professors can say things that really feel shameful or embarrassing or sometimes there’s the pimping, where a student is asked question after question until they can’t answer it, and there’s then that sense of well you should have known the answer and clearly you’re not coming up to the level that you should. It sounds like that wasn’t your experience, but certainly there’s been I think at least anecdotes that that occurs. Let me just see if we can pull in Lara here. How will we get at studying this phenomenon, and also I wonder if you have any experiences you’d like to share with the group?

Lara:                    Of course. David, you ask a really important question, because studying these kinds of emotional experiences as they happen in learning is something that we have to do… Let me restate that. Is something we have to do, period. But it’s also something we need to be very cautious about and not because it’s unearthing bad things or that in some way we shouldn’t be asking these questions. In fact, we absolutely should, but this is unlike much other research that happens in medical education, where we might ask questions about what was your experience doing this kind of test. Or what were your experiences in this kind of flipped classroom. Which have important insights to offer but usually are relatively benign when it comes to the impact that has on our participants.

Lara:                    But when we’re studying something like shame, and we are asking people to tell us their narratives of a shame experience, we have to remember that in studying these things, we really are doing something to our participants. We’re asking them to relive a very difficult situation. So I think in terms of our research efforts in this domain, we need to be treading very carefully and doing it with much intention.

Lara:                    This is not a situation where after the interview, and I will suggest that doing this qualitatively is probably the first set of right studies that needs to be done, because we don’t understand the experience yet. But this is not one of those situations where once we’ve done our interview, I’ll give you your five dollar gift certificate to Starbucks, I thank you very much for the interview and off you go. Because we kind of just started something with them. That we need to make sure that that participant walks away with support. They know they’re not alone, that there’s counseling available, and that what we just started is not just arbitrarily over because the interview itself is over. So that’s the first part to your question. I think we have to study it. We just have to be very thoughtful and careful about it.

Lara:                    The other thing is that I think the other part that I’d like to just bring into this conversation is that we’re talking about the experience of shame from a trainee perspective, and Will and I and some others have done, and Ashley of course, have done research looking at this from the residency perspective, and from the medical student perspective, but I think we have to remember that shame is not an experience that is limited to our learning years. So as faculty members it happens that we find ourselves in situations where we re-find shame or feel shame.

Lara:                    I can tell you about one of mine, because it’s one of, it’s not the only time. But when I went up for promotion from associate to full professor, this is really a moment in an academic’s career where you are literally being put beside a standard of some sort and being evaluated as to your capacities, your abilities. And despite feeling rather confident that everything was going to be okay, I was turned down for promotion to full professor the first time I went up. And that was really a moment for me of shame.

Lara:                    I felt, and as the others have commented on, perhaps there was after finding out more information about the situation, I understand there was actually a time and rank situation involved that I didn’t really understand, but that initial reaction was that the background of my life started to resonate in my ears, where I grew up in a space where as a woman I was not expected to necessarily become a professor, that as was pointed out to me once, that the expectation was that I would be a secretary and not have one. And so to be in a situation where you’re turned down for a promotion, all those voices come back and then all of a sudden there I was, finding myself thinking that I am so ashamed. I don’t belong here. I don’t have what it takes to be successful.

David:                 How did you cope with that? How did you react to it?

Lara:                    Oh David, what a nice question. It was ugly. It was a very emotional experience for me. What I did first is I locked myself in my office and had a really good cry. And then I did probably the smartest thing I’ve done ever. And reach out to some people that I really trusted who were also scientists in academic medicine, and understood not only the context but what it meant for me to be in that situation. Those friends are people to whom I owe a debt of gratitude that I could never repay except to keep telling them how much I appreciate them being for me there, at that moment when it wasn’t a pretty phone call to answer.

David:                 It sounds like again, just as what Ashley was saying, that having this group of colleagues, peers, community, are really an important antidote to the emotional reactions that probably we all have at some level that go way back to, as I think Lara you’ve said, going back to probably your childhood experience or messages you got from your mother and dad, some of which probably were not all that helpful. Will, I know you did some research in this area? Do you want to share a little bit about your research?

Will:                     Yeah, so Lara and I have done, involved with some other colleagues and trying to study this from a qualitative and somewhat foundational perspective, with no preconceived notions about how an individual in our context and environment might experience shame, but rather from a truly exploratory space that focuses not only on a person’s own experience, but how the environment or the context influences that experience. And the methodology we’ve chosen, which is hermeneutic phenomenology, it actually allows and requires that we bring our own experiences of shame and the phenomenon into the data analysis process. So it’s a very engaged and frankly vulnerable methodology to use.

Will:                     We first studied this as medical residents. We published that paper a few months back in the Journal, and we interviewed twelve internal medicine residents at a large teaching hospital about their shame experiences. And we are repeating our methodology and current study in medical students in which we interviewed eight students who just completed their first year, preclinical year, and then eight students who had just completed their clinical year, and talked to them about their shame experiences. And we’re developing kind of a deep and rich and multi-faceted and frankly overwhelming understanding of this really, really complex but powerful phenomenon.

Will:                     I’m happy to share some findings from our research as relevant to the conversation, but that’s been the approach so far. We plan on studying this in early career physicians as well to try to capture that additional transition period out of the learning environment as a learner into independent practice.

David:                 Well, so this is great to hear that you’re doing this work, because I think many years have gone by without a whole lot of emphasis on this. I wonder if all three of you could kind of just sort of give some helpful hints or some suggestions to others who might be listening to this and may be experiencing their own doubts or experiences of shame, what would you suggest? What should they do or how can they cope or prevent this from happening? Any ideas about that?

Will:                     Yeah, I can start. I reflected on this before the podcast, and I really think we need to talk about this at a couple of different levels. One of the biggest findings from our research that sort of continues to emerge from the analysis is that shame is an experience that results from an interaction between a person and an environment. And that interaction is unique to that person and to that environment. And what that means, among many things, is that we can’t focus solutions on just the person or on just the environment. It’s also occurring within a broader culture, both societally and within our own profession. And so we have to come to this from those three different perspectives in my opinion.

Will:                     When we think about how do we practically help someone recover from shame, the first is at an individual level. The first thing we have to do is just look for it. If we don’t look for it, we will not find it. And if we don’t know what it is and don’t know what it can look like and sound like and feel like and how it can be described, we’ll miss it. And so one of the kind of fundamental goals of our research is to get that information out and to educate people on what this emotion is, how it sounds, and what it feels like.

Will:                     Well even before recognizing, we also need to create the conditions in the environment to be able to express it or to be able to ask about it and have it shared openly. And then once it’s identified, we need to provide active support. We’ve found in our research that people who experience shame, often are passively postured towards help. They aren’t running around, sort of waving their arms, with a big sign saying, “I’m shamed. Please help me.”

Will:                     Rather they’re doing the opposite. They’re hiding. They’re minimizing. They are isolating, and they’re not necessarily inherently ready to easily talk about that. And so we had to provide active support. And that starts with just asking about the shame, and one of the best ways I’ve found to do that in practice with learners and colleagues and even my family and friends is to go beyond saying, “How are you feeling?” To saying “How are you feeling about yourself?” We need to get to the self level, and we often keep that level kind of hidden away the furthest.

Will:                     Once we’ve identified it, we need to name it and we need to validate it. So there’s a lot of power in saying, “I think you’re experiencing shame.” That was huge for me. And then when you just say, “It’s okay and it’s normal. This is a normal human emotion.” It does have social benefits of course. Misplaced, prolonged or overly intense shame is typically destructive. But it’s a human emotion and we need to validate that and then we need to normalize it by saying ideally, “Hey I’ve experienced this.” We need to model vulnerability. We need to talk about our own experiences and make it an okay thing to experience and to talk about.

Will:                     And then once you’ve done that, and kind of built the trust, further the conversation, it’s very helpful to get a person to shift the blame from themselves onto something specific that they can change.

David:                 More of a behavior kind of thing. So into more like the guilt as opposed to shame. Is that what you’re thinking?

Will:                     Exactly. You’re just transitioning from a shame to a guilt reaction. And that occurs first and foremost through some self-compassion and self-forgiveness. I often say to learners that I’m working with on this is just say, “Hey I need you to forgive yourself real fast. And let’s process that part of it but then let’s move off of you and onto something that you can fix.” That’s a much more empowering stance to take, particularly in the midst of a really difficult failure or perceived failure. And so that’s all at the individual level of course.

Will:                     Then you need to provide ongoing support. We’re also learning that the shame does not stop after the most intense portion of it following the trigger. The shame can persist for weeks to months to years and it can come back and it can be a ruminating type of shame. And it often requires sort of prolonged support and ability to talk about it openly. And the last thing I’ll say is that all of this needs to happen within an environment that instills psychological safety in which vulnerability is modeled and valued and appreciated and in which we are focusing on practice is growth, and using strategies to encourage learning that don’t shame but rather facilitate healthy performance, improvement and growth. In a more sort of guilt-oriented fashion.

David:                 Good. Ashley, how about you? Any suggestions you’d like to provide to our listeners?

Ashley:                Yeah, I think that from the medical student perspective or the resident perspective, you mentioned earlier the teaching method that people commonly refer to as pimping, some may call it the Socratic method, whatever you want to call that, I think that there are ways to challenge learners in sort of that public way by asking them questions in a way that isn’t as destructive.

Ashley:                So I think that there are some ways, where as you mentioned, you can really put someone on the spot, hammer someone down with questions until they get some one wrong, I think that’s sort of the destructive way that most people think about that practice. But I’ve had some of my favorite teachers on the wards use that method of okay, we’re going to be here on rounds. We have this interesting patient to talk about, and we are going to find the holes in our learning. And the way that they’ve done it in a way that excites me and gets me excited to engage in that learning, is when they frame it as okay, we are all at different stages in our learning, and every one of us has something to learn from this patient, whether that’s the senior resident or the medical student. And so none of this is about putting anybody on the spot or identifying weaknesses. It’s really about just finding the areas from which we can learn from this patient.

Ashley:                And so I think that does two things. One, it sort of up front prompts that this is an opportunity for growth. And then two, as a medical student I remember watching the upper level residents also finding areas that they can learn, and so when I as a medical student say, “Okay I didn’t know that, and that was at my level, that’s another area where I can grow,” it’s okay because I know that the residents are also in that sort of same growth mindset. And it sort of normalized that it’s okay to be learning.

David:                 That was terrific, thanks. Lara, any suggestions from your perspective?

Lara:                    Sure, I’ll just add one or two things just to build on what Ashley was saying. We are all still learning, so that means medical students, residents, faculty members. We all are still learning. What is it the saying says? The more you learn, the more you realize you don’t know. There’s just a greater body of knowledge out there for us. So even the faculty members, by acknowledging that we are all learning. There is going to be a new drug, a new whatever that as a faculty member I don’t know about.

David:                 Sometimes it’s hard for the faculty to admit that they don’t know something, because I think they feel like they’re expected to have the answers, and they don’t always have them.

Lara:                    Right? What a challenging space to be working in. To feel from yourself that I need to have these answers all the time to support these learners. What a surreal amount of pressure, to find yourself working in. And I think that’s the other point that I’d like to make David, is that one of the things that comes across in our data time and time again when we’re looking at it is just the extent to which there is a static in the air in our learning spaces when it comes to medical and health professions education. There is so much pressure being put on our learners, on ourselves, that the question isn’t I think if shame events are happening. The question really is when are they happening, because all the ingredients, that static is in the air and it just needs a spark.

Lara:                    We can’t always tell what that spark is, so I think that the goal for us as faculty members then is to recognize how much pressure a lot of our learners are putting on themselves, how much pressure we put on ourselves, how much caring and investment and emotional energy goes into making medical education a success, and then trying to say how can I try to first of all distill some of that pressure so that we’re all learners? And second of all, what’s happening with my learners? Has an extrovert turned into an introvert? Has somebody missed an important meeting? And instead of calling them out like, “What’s wrong with you?” But then asking as Will suggested, “Are you okay? How are you feeling about yourself right now? Can we take five minutes and just talk?”

Will:                     I just wanted to piggy back on one thing that both Lara and Ashley referred to, and it’s essentially the shame that can result from normal learning processes. And this is all over our data sets in both studies, where people experience shame from what would be considered inevitable or unavoidable learning struggles that are part and parcel of a learning process. And one thing that we also have seen is that there is a significant value placed on performance, and learning and performance are often interwoven, such that often learning takes a back seat to outward performance of a task.

Will:                     And I think, as I’ve reflected on the notion of the performance in medical education, I think we’re actually using the wrong word. I don’t think our learners are performing. I think they’re rehearsing. A performance signifies a polished, completed process of rehearsal, and as I’ve thought more about that I’ve thought about the value of seeing learning as a rehearsal. It allows for exploration. It allows for screw ups. It allows for falling flat on your face. It is built upon the expectation that you will learn and grow and improve towards a performance, but it allows for more of those things. And I can tell you many of our students do not think that those things are allowed and therefore when they occur, they have the potential to be seen as indicative of a globally flawed self. So I’ve had a lot of success telling learners, “I want you to see yourself in rehearsal right now and not in performance,” and it’s amazing the extent to which that frees them up.

Will:                     And there is one caveat to that, which is that the notion of rehearsal as you progress through training gets harder when you start to bring patient care into the mix and responsibility. Because now they’re a rehearsal with real consequences on people. So it’s not as simple as just that basic of a metaphor, but I think it is a powerful way to view learning.

David:                 That’s great. I want to shift us for just a moment to one other thing that we haven’t talked about, which is the unique experience of our students and faculty and residence who are different in some way. Either they’re a minority, maybe they’re LGBT, maybe disabled in some ways, but that they don’t necessarily feel that they’re being perceived as being perhaps fitting whatever the mold is that they think a physician should be, based upon reactions of people around them. I think this is sort of related to this shame experience. Any of you want to just say a word or two about that?

Lara:                    I think that’s really astute David, I think you’re absolutely on point. And our data is suggesting to us that those people who are not as well represented within the context where they are learning and working do find themselves in a situation where, again that static is in the air, but boy do they ever feel it. And understandably so.

Lara:                    I would like to believe that as our institutions evolve and change and inclusion and participation from more and more populations is brought into our communities, that this will evolve. But I think we do have to be paying very careful attention and supporting those learners who are in some ways not represented as thoroughly in our populations, because they are keenly aware that they are not represented there. Will, you probably have more insightful comments than I do.

Will:                     Yeah, no, I’d love to go a little deeper with it. That’s been a real powerful and interesting finding with our current study that frankly I wasn’t expecting to be so sort of pervasive across the data set. When people tell us about their shame in medical school, they talk a lot about the ways in which they are underrepresented or they perceive themselves or are outside of the mainstream. And we have a list of the ways in which this manifests, and that list includes some of the traditional ways of being underrepresented or the more easily identifiable potentially, with gender and race, some related to sexual orientation, to gender identity. We also have things like educational background and being from a different part of the country. Being interested in primary care instead of a specialty.

Will:                     And each one of these things, which are unique to a person in his or her individual makeup, contribute to shame reactions in the medical learning environment. I mean, that’s a significant, I think a significant experience, and what we’re kind of maybe concluding from that is that shame may not just be related to what I did, but there also may be shame related to who I am. And I think that that has some powerful connotations for how we think about instilling true belonging and true inclusion, not just in who we recruit but in how we help them or facilitate their integration into the learning environment and into the profession.

David:                 Yeah, thank you Will. I think that’s so important, and in fact in my book Outlooks of Men I do bring up those experiences of the students who didn’t really fit the mold at least at that time for the elite prep school. So I think it kind of is probably pervasive, particularly in those learning environments in which there’s sort of almost a class difference in terms of what people are by and large being expected to do and be and represent as opposed to a really inclusive population. But Toni, are there some other things you’d like to bring up? I know we’ve kind of ranged all over the place here a bit, but some other things that we need talk about?

Toni:                    Sure. You guys have talked about some of the research that you’re doing now. Will and Lara mentioned your study with medical students. I wonder if you can talk about other work going forward. Kind of what are the next steps for this research, and Ashley maybe some of the things that you’re doing at your new institution or areas where you think we could be doing more work?

Will:                     Sure. Ashley, you want to take a crack at that first, just from your experiences on the ground?

Ashley:                Yeah, absolutely. One of the things that I’m most excited about as a resident is to have the opportunity to sort of promote a culture of vulnerability both among my resident class, within spaces where I’m interacting with other residents and faculty, but also in my role as a teacher of medical students. I’m three weeks in now, haven’t had too many opportunities to really put that into practice, but I have noticed that there are moments where, when I’m interacting with a medical student, I feel so in touch with what they’re going through and I can identify with a lot of the emotions that I can sort of see them working through.

Ashley:                And obviously of course that has to do with the fact that I am closer to being a medical student myself than to being a senior resident. But I think that that’s a feeling and an emotion that I’m hopeful that I can maintain. I hope I don’t ever lose that feeling of what it’s like to be sort of this newcomer on a team and to observe a team full of residents and faculty who seemingly have developed relationships with one another and yet, you’re sitting there feeling a little bit like an outsider to this team and the dynamic. And I hope to embody the traits and sort of that welcoming nature that I felt as a medical student from some of my favorite residents.

Ashley:                And then in terms of promoting sort of a culture of vulnerability among my resident class, I think that that responsibility falls on every single one of us. And I’d like to think that even in the smallest and the most simple of ways, that we can promote that by just putting it into practice. When I’m having a tough day, or if I felt uncertain about my abilities or made a mistake, I am striving to share that with people, both to promote sort of that shared sense of struggle and to combat my own shame response, but also to allow others to say to themselves, “Okay this is okay. I know that I’m feeling this way, but I also know that this is a normal part of the learning process and something that all of my other co-residents are feeling as well.”

Ashley:                So I’m hopeful that sort of in an informal way, I can impact the environment. I think that’s sort of the responsibility that each one of us has, and if you add all that up, it can sort of spread. That’s the ultimate goal. And then of course, I’m looking very much so forward to interacting with these topics and this work on a formal way as well moving forward as part of my residency program the next five years.

Will:                     Right. So I can kind of quickly pick that up from where Ashley left off, and I see the future of this work sort of in three pillars. One is driving the understanding and discussions around this topic more informally. And we’re attempting to do that in some somewhat creative ways.

Will:                     We just worked with a documentary film company through a grant, through our educational consortium here, Duke Ahead, to create a short documentary video in which we interview and talk about our shame experiences with interprofessional healthcare providers. And we’ve created a website that will house that film and then some resources that can be used in workshops and in conversations about it, and it’s called The Shame Conversation, and it will launch in the second week of August. The goal with that is just to try to get people to start talking about this and to make it part of our normal discourse.

Will:                     The second pillar is the more formal programming where we’re working to develop, we wrote up an innovation report about a seminar we did in shame and medical students, that has already published ahead of print in the Journal. We’re developing additional seminars related to that, and we’re testing them to see if they’re having their intended effects. And over time, we’re kind of linking them together into curricular arcs that provide touchpoints across the four years for our students to engage with difficult topics related to shame.

Will:                     And then thirdly, we’re continuing a research program around this. I’m currently doing PhD work with Lara and Pim Teunissen as mentors at Maastricht University, and we are striving to generate a theory of shame in medical education over a program of four studies. And we also have plans to take our data that we’ve already collected that we haven’t published related to how people recover from their shame and develop resilience to their shame to shine more light on the way that we can be resilient and grow from this emotion. So it’s really exciting. There’s a lot of different directions. And it’s what we’re very passionate about and fortunate to be doing.

David:                 Oh that’s great. Lara, anything you’d like to a dd?

Lara:                    The only last comment I’ll make then David is that we have to remember that, like so many other things that we’re talking about in our community right now, wellbeing, resilience, shame is a feeling that’s experienced by the person, but it’s an experience that is also within a context and so that context is playing a role. So as we move forward and try to think about how we can enable learning to happen and to recognize that shame happens and support learners going through the process, we also have to be critical and think about and hopefully study how our context, how our learning spaces or creating spaces where these situations are very likely to happen. What is the static we’re putting in the air, and how do we start to pull that back?

David:                 Sure. So describing the environments that are really most toxic, I guess in a way you might call it, that would encourage in some ways these shame experiences versus discouraging them. Well I think we probably need to end here. We’ve kind of run out of time, but maybe just have some final parting words from each of you. Why don’t we just let each of you, if you have anything further to say then why don’t we do that, and then we will close. Will, do you want to say anything further?

Will:                     Yes. It’s very hard to come up with one final thing to say. I have so many. One thing that’s been rattling around in my head as we’ve talked is that I think it’s going to require large-scale vulnerability and transparency in our culture and our community at large to take ownership of this, of the role that shame plays in our education system.

Will:                     In many ways, it has come along as a pedagogical strategy in a lot of learning environments. It’s been baked into the way that we learn and the way that we care for patients and who we are. And that’s okay. And I think we need to be open about that and accepting of that fact so that we can begin finding ways to change the way that we teach and change the way that we go through this experience, in sort of a more growth-oriented, self-kind and compassionate and constructive way. So I hope that everyone else who’s doing this work and who believes in it will get on board with that wide-scale vulnerability.

David:                 Ashley?

Ashley:                Sure. I think the biggest thing for me when I think about this work is one, an expression of gratitude to the teachers, the faculty, the mentors who are willing to put on display their own vulnerability. From the perspective of a trainee, I can’t tell you how meaningful it is when I witness vulnerability and the faculty member who’s confident enough to display their uncertainty for others, for trainees, for learners to see.

Ashley:                It’s so important for us to see that, because we can’t do it if we don’t see the people who we are trying to emulate do it. And so I do think that, you know, as learners, we have an opportunity to model it for each other, but it is so important to be observing that from the top and the people that we’re learning from. So I think it’s just sort of an expression of gratitude for the people who are able to do that and a request to the people teaching us to continue to sort of integrate that into their teaching practices.

David:                 Great. Lara?

Lara:                    So I too want to make an expression of gratitude, and at the risk of perhaps sounding a little sappy here David, I want to thank you and Academic Medicine, because what have you done but provide a platform and really be very supportive of this work? When we first submitted to Academic Medicine, here we are talking about shame and that’s never been on the radar before, and Academic Medicine not only saw the merit of the work but helped us to work on some manuscripts that were challenging for us to put together. And then also that the importance of this work, via this podcast, via other publications, the AAMC news, I think just a tip of the hat to Ac Med for not only supporting the work via publication but highlighting it, promoting it, putting it out there. So that’s what I’d like to say.

David:                 Well thank you. And yeah, I think we feel really good about being able to be a forum for that, and one other thing I do want to say is there’s been a lot of work recently and publication around the issue of trust and entrustment, and I think that there’s probably that connection, the trust between students and faculty and relationships that are positive, that provide I think what Lara, what you said in terms of that environment that helps to counteract some of those experiences that could lead to shame, I think is also really important. So I think trust and entrustment and all of that is maybe a way forward. I think we need to close. Toni, any last words?

Toni:                    I just want to thank you all for being here today to participate in this discussion and for all of your work on this topic. We’re excited to be able to highlight it.

David:                 All right, goodbye everybody.

Ashley:                Thank you.

David:                 Bye, and thanks again. [crosstalk 00:43:25].

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