On this episode of the Academic Medicine Podcast, guests Will Bynum, MD, and Joe Jackson, MD, join host Toni Gallo to discuss new research into the nature of shame experiences in medical students and emerging work on the implications of premedical students’ shame experiences for their professional development. They offer advice for educators and learners for naming, normalizing, and addressing the effects of shame and provide suggestions for fostering a safe, inclusive learning environment and a holistic admissions process that support learners and minimize opportunities for shame triggering experiences.
This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.
A transcript is below.
Read the article discussed in this episode:
Bynum WE IV, Teunissen PW, Varpio L. In the “shadow of shame”: A phenomenological exploration of the nature of shame experiences in medical students. Acad Med. 2021;96:S23-S30.
Transcript
Toni:
Hi everyone. Toni here. Today, I’m joined by Drs. Will Bynum and Joe Jackson to talk about their research into the nature of shame experiences. Last year’s RIME supplement included a paper by Will and his colleagues entitled “In the Shadow of Shame”: A Phenomenological Exploration of the Nature of Shame Experiences in Medical Students, which you can read for free at academicmedicine.org. And I’ll put the link to that article in the notes for today’s episode.
Toni:
In our discussion, we’ll talk about that study and some new work that Will and Joe are doing into shame experiences in premedical students, as well as some other work as educators that they have going on. You might remember Will from past episodes. He currently serves as an assistant editor for the journal. And back in August of 2019, he joined the podcast to discuss his research into shame experiences in residents. In that discussion, we got into what shame is and isn’t, how it can be studied, as well as the importance of naming shame and normalizing it as an emotion that everyone experiences.
Toni:
And I shared that conversation on the podcast again last week. I encourage you to go back and listen to it if you haven’t already. It’s called “I Need You to Forgive Yourself”: Shame in Medicine and Medical Education. And with that, could everyone introduce themselves? And then we’ll get into some of the work that you’re doing now. Will, would you go first?
Will Bynum:
Sure thing. I’m Will Bynum and I’m a family medicine physician and residency program director at Duke Family Medicine in Durham, North Carolina, and really appreciate the opportunity to speak with you and be on the podcast again.
Joe Jackson:
Hello, I’m Joe Jackson, delighted to be here. I’m a pediatrician, primary care pediatrics. I also serve as associate dean for student affairs and advisory dean for our school of medicine and have a role with our masters students, our preprofessional students mostly with an interest getting into medical school.
Toni:
Well, I want to thank you both for being on the podcast today. In your paper, you describe shame as occurring when an individual blames something global or unchanging about themselves for a negative outcome. And I thought we could just start with a little bit about what we know about shame, what we still don’t know about shame, and its effects in medical education.
Will Bynum:
We know less about shame than we do know about it in medical education. It’s continually surprising to me how little it’s been studied and talked about. That’s beginning to change with a cohort of really amazing researchers that are shining a light on this, but a lot of the work we’ve done and that others are doing now is foundational and exploratory in nature. And it’s primarily being done qualitatively, which is giving us insights into the nature of this experience, the depth of the experience, and how it affects the person, how it feels, what it makes them want to do.
Will Bynum:
And so we’re really beginning to capture some of the essence of what this emotion feels like and how it functions. What we don’t know is, other than anecdotal experience, how common it is, how widespread it is, with what it’s associated, really why it happens the way it does, how it’s embedded in our culture, in our institutions. We have some data and some signals saying that all those things are present, but we don’t understand nearly the extent to which shame functions in medical education relative to the role that it’s playing.
Toni:
And on the episode from last week, Will talks a little bit about how he got into this work. And I wonder, Joe, if you could tell us a little bit about how you came to study shame or think about its impact in your clinical and educator roles.
Joe Jackson:
Happy to. So, one of the things that I’ve enjoyed doing is spending time as an academic advisor, and I’ve had opportunities to advise students who have a really strong interest in getting into medical school. And then I also have the opportunity to advise students who are in medical school, and it’s been very unique to sit at the frontline and listen to students describe their challenges, the things that have occurred to get into medical school and the things that occur to them as they’re trying to maintain as a medical student. And that’s really where my interest has come in, really desiring to think about some of the influences and challenges that individuals have both at the gateway before they get in, and then as they jump into medical school. So, that’s where my interest stems from.
Toni:
Thanks. I wonder if we could talk a little bit about some of the findings then from the RIME paper and then maybe how you’ve seen that play out in your practice for both of you. So you talk about shame as a destabilizing emotion. You use the metaphor of dominoes and when one domino falls, it affects the rest of them in the line. So, Will, maybe you can just talk about kind of how that metaphor came about and then both you and Joe can talk a little bit about how you’ve seen shame as a destabilizing emotion in students.
Will Bynum:
Yeah, so this paper and study really focused on once shame has developed, and in the previous paper, we helped to characterize some of how it develops by describing the triggers and the contributing factors that lead to the development of shame. This paper really focused on its nature, once a shame experience or reaction has developed.
Will Bynum:
And this was a great study for a phenomenological approach because we were really examining the structures of that experience. And that took us into the affective feelings that occur with it, the cognitive processes, the action tendencies, the effects. And analyzing those elements, we were struck by the incredible complexity of a shame reaction. Any given shame reaction as an amalgam of a lot of different cognitive, emotional, and physical processes. And as we analyze that, those processes and those elements, we identified an emergent essence of shame in medical students and likely in most people, because it is a human emotion, as an emotion that can really destabilize one’s sense of self.
Will Bynum:
It is emotionally destabilizing. So people talked about feeling “like the floor was dropping out from under me,” when they were feeling shame, like they were falling precipitously. Those are some of the physical destabilizations. Emotionally it could lead to a lot of anxiety, fear, perceived judgment, often manifested as an affective surge that was akin to some fight or flight type responses. And then we identified cognitive processes that led to destabilization. So depersonalization, disorientation, having difficulty accurately self-assessing relative to objective reality.
Will Bynum:
And that was a phenomenon we call the skewed frame of reference, where I see myself in a much harsher light than objective reality would dictate. And sort of the net sum of all of that was this notion of destabilization in which a person can lose a sense of self, their grounding in who they are, and in their ability to understand themselves in an accurate and positive light, all within a shame reaction, with effects to follow.
Will Bynum:
So that was powerful to us because, if we are destabilized in a shame reaction, then it follows that we likely attempt to restabilize. And how to support that restabilization and to prevent some of the profound destabilization that can occur has implications for us as educators.
Joe Jackson:
And then I would add just practically when students do come in, often they are unaware of how deep some of these shame experiences have actually affected them. And so I have found this paper to be hugely helpful in our ability to just have a category for talking with students about what to do with the things that are underlying the problems that they’re facing. And so when a student comes in with a particular challenge, there’s now an opportunity to really help them to think through, well, what are the factors and influences that are underlying how you’re perceiving yourself at this moment or what are the underlying factors that may have affected some of how you are experiencing shame as it relates to the things that you’re trying to get through within medical school.
Joe Jackson:
So I’ve just enjoyed the opportunity to maybe bring some practical application as I’m talking with students to really help them to think through, of these experiences that you’ve had, how far do they go, and what are the opportunities ahead to maybe think about what needs to change going forward to make sure that you’re not inhibited by some of these experiences.
Will Bynum:
Yeah, Toni, you asked me about the metaphor and to Joe’s point as well, this was something that really has come up in all 3 studies, the tendency or the potential for shame to lead to runaway thinking and runaway self-evaluation. And it’s kind of a part of that skewed frame of reference in that: in response to a shame trigger, a given shame trigger, making an error, being mistreated, being different than the norm, you can develop an acute sense of global inadequacy typically related to that event.
Will Bynum:
And in the midst of a profound shame reaction, and not necessarily all of them, but a profound one, that evaluation around that specific characteristic or quality of yourself — so if I make an error, I’m an incompetent resident — can quickly spiral. And this is where the metaphor of the dominoes comes in. The dominoes falls, and then progressively more dominoes fall, not just in a single line, in kind of concentric circles, or like a spreading wildfire where more and more of the person’s sense of self and identity and how they know themselves are implicated as this runaway thinking progresses. So I make an error and I’m an incompetent resident, and then I begin thinking about, am I a competent father, caregiver? Am I socially competent?
Will Bynum:
That was particularly the case if someone was being mistreated or marginalized in a group, the tendency to take that treatment and say, gosh, am I inadequate in all my relationships? Is there something wrong with me as a person, not only within this teaching team and in the hospital, but outside of the hospital as well? And that runaway thinking could actually quite quickly lead to a really widespread global negative assessment of the self that left little room for self-validation or could completely drown out that voice of you are good enough because the voice telling you you aren’t in so many ways is just so predominant.
Toni:
One of the other things you talk about in your paper, Will, and it’s come up in this conversation already, is that responses to shame are similar to responses to trauma. You described physical manifestations, emotional, cognitive, behavioral, and I wonder if you both could talk about both sides from the educator perspective. How does that play out in creating a learning environment with a growth mindset?
Toni:
You want everybody to come and feel comfortable learning and growing and admitting when they maybe don’t have an answer, but at the same time, there’s this sense of I’m a bad doctor if I don’t know the answer to this question. So how do you create that safe environment? And then also maybe Joe, what do you tell your students who feel that? How do you help them through those experiences? Maybe Joe, do you want to start from the student side and then maybe we’ll talk about the learning environment?
Joe Jackson:
Sure. So I do think that there are many factors involved when a student comes and has experienced any sort of trauma and trauma related to their learning environment. Having experiences where they’ve had shame events occur, maybe it’s happened chronically. There’s a lot that they bring to the table that really needs to be unpacked. And I think that a starting place is first just to normalize for students, that what they’re experiencing are real, they run deep and they’re common.
Joe Jackson:
And so that’s probably the first thing that happens is having a conversation with students about the reality of shame and how that can affect multiple people and they are not alone in that. I think I also moved pretty quickly trying to think about the environment they’re in, and this is probably any traumatic event. It’s really important not to re-traumatize someone. And so trying to create spaces where they feel some comfort and confidence to explore the emotions that they’ve experienced.
Joe Jackson:
And so recognizing, helping them to recognize, that these things are difficult and they need to talk to folks that they feel comfortable speaking with using the resources before them to help them get at some of what they’ve experienced. Those are kind of the places where I usually would begin with my students.
Will Bynum:
Yeah, the construct of trauma has been fairly prominent in both our medical student study and now in our pre-medical student study. It first came up in the medical student study when, in the process of identifying and analyzing the phenomenology of shame, we found a lot of the phenomenology of trauma and there was a lot of overlap. And what that suggests to us is that events that are causing shame in medical training may appear to also have overlap with trauma, such that these shame triggers could also be traumatic events. And what’s important about that is that many of the shame triggers we have found in all 3 of our studies occur during normal learning.
Will Bynum:
So being wrong in public, getting a lower grade on a test, not being at the top of their class. Particularly those that are more public can in and of themselves constitute traumas, especially if the environment responds harshly to the person experiencing that. We also have found, more so in our premedical student study, that people bring existing trauma through the gateway of medicine and into our institutions and into the practice. And I think we are woefully unprepared to help people engage with that trauma, A, and B, create environments that really mitigate the risk of re-traumatization. And so there’s a small, but growing course of researchers that are talking about trauma informed medical education, borrowing from principles of trauma informed care. And so there’s a great couple papers out about that in the last few months, maybe we can link them in the comments as well.
Will Bynum:
I also want to just mention my colleague Luna Dolezal from the UK, University of Exeter, is beginning to write about the notion of a shame-sensitive environment in conjunction with the idea of a trauma-informed environment. And I really like her emphasis on shame sensitivity, even more so than shame resilience, because it requires that all of us working in an environment where the risk of shame is inherent, and our research has shown that it is absolutely inherent in what we do, the risk of it, that within these environments, we need to maintain awareness of the possibility that shame is ever present. And by maintaining that awareness and being prepared to support someone who is experiencing shame or has experienced trauma, or who is very likely to be re-traumatized or to experience shame, that that should be a minimum standard for any of us that are educators and also just good people, colleagues working together in health care.
Joe Jackson:
Just as you mentioned, just the sensitivity that’s required, it reminds me of just one of the unique findings of this premedical study is the type of events that can actually induce shame. And so when you have providers, medical educators, who are well intentioned, there are still opportunities to do harm. And so even something as simple as an orientation activity or something as simple as organizing a small group event for a group of students, if there isn’t an intention and sensitivity in how those events are designed, they actually become key opportunities that can actually induce shame in students who may have had that before and are almost predisposed to have those events result in additional shame.
Will Bynum:
Yeah. I’m going to give you an example of that. That’s such a great point. And an example from our research is a student from a somewhat underrepresented background in that she was first generation college student, certainly first-generation doctor, from a public institution, had excelled despite a lot of barriers placed in front of her and had overcome a lot of adversity, found herself in a medical school orientation in a large classroom with other students.
Will Bynum:
And the simple activity of having everyone around the room tell their name and their institution threw her into a major shame spiral when most of the students were from prestigious institutions. And then that single piece of information plus her own insecurities and some of her own uncertainty about whether she belonged in health care as someone from a more underrepresented background, they interacted and she silently suffered significant shame during that event that nearly impeded her willingness to apply, at least to that institution.
Will Bynum:
So something as simple as having everyone tell their institution, as opposed to something maybe a little more personable or a little more unique to them as just a human being that doesn’t have such a label attached to it, can be a simple strategy and I’ve actually tried that in a workshop and it seems to work. So what Joe’s getting at really is that we need to be vigilant about the big and small things in our curricular structures, in our cultures, in the way we do things that may bring with it risk of shame, particularly for those people who haven’t been represented by the dominant norms historically.
Toni:
One of the other themes that comes up in your paper, Will, is the additional opportunities for shame for students that are from groups that are underrepresented in medicine. And I think Joe mentioned this idea of chronic shame, where even if there isn’t a triggering event, students will feel shame. And I wonder if we can talk a little bit more about that and maybe some additional ways to help foster an inclusive environment for all students and how thinking about that layer of shame might come into it.
Will Bynum:
Yeah. I’m going to make a couple quick comments then let Joe share his thoughts. This is something we talk a lot about in our current study. It’s shown up a lot, the role of underrepresentation in shame. Where it really got onto the radar with our research was in our medical student study looking at the origins of shame where we found that people didn’t just experience shame because of things they had done, like making an error or screwing up a presentation, but because of who they are. So such that if I’m an African American male from a low socioeconomic background, I feel shame just by being who I am in a space or by walking through the front door on day one of medical school, I feel a sense of inadequacy and a lack of belonging. That then can be reinforced through subsequent events, particularly if they suggest to the person that they truly don’t belong or that they’re an imposter, et cetera.
Will Bynum:
So that was really powerful to us because it really began to shine a light on the notion of shame based on identity and background and then we’ve begun to learn a little bit more of where that might come from and looking at the premedical pathway. Joe, will you share some of your thoughts that you shared with me along the way?
Joe Jackson:
Sure. So, so just the example you give of the African American male who may experience higher levels of shame because of his background or personal experience, it goes in a number of directions. So we’ve also seen in this work that there can be added pressures. So if you come from a marginalized group and you may actually be seen as the overachiever, and there is an added expectation that, because you’ve made it, you are someone who has to succeed. The fear of failure and the perceived notion that you are not in a position to not do well, a lot of people suffer from that.
Joe Jackson:
So I think that ends up being a big part of being marginalized and coming into a space where you may experience additional shame, and it actually at some level triggers an added sense of feeling like you don’t belong. So that example that you give, that is definitely something that I think is emerging from this study and also is actually seen as I have conversations with the learners who come into my office. I think another part of this is just the pressure that can come for learners who have experienced shame over many years, which may relate to their marginalized background. And I think it also has to do with some of the perceptions that that individual may have as they move forward in a space where they don’t always feel like they may belong. And so I think that fear of failure, I think that pressures that are both internal and external, some of those pressures come from past advisors and family members and loved ones who have been with them beforehand.
Joe Jackson:
And then there’s also the pressures that they experience externally from others within the environment where they’re trying to learn and grow. I think that all of those things together add to the weight that certain individuals experience when they’ve had shame experiences and when they try to rebound from those actual experiences. So as I’ve had opportunities to sit, particularly with some of our marginalized students, these are common topics that they don’t always have words for, and they don’t always have categories for what they’re feeling and where it comes from. And so I have tried to just begin to unpack a little bit with them, where those notions come from, how those experience may be affecting how they’re making decisions, how they’re viewing themselves. And then it becomes an opportunity to have some conversations going forward about what to do about that and how to maybe quiet some of the inner voices in your head that are making you feel like you’re not enough or acquiring some of the voices that are making you feel like you don’t have what it takes to succeed.
Joe Jackson:
So just trying to bring some of that to the light and giving them some of the words to identify some of what they’re feeling, I feel like it’s been a way to move forward, given some of the challenges that this population of students experience.
Will Bynum:
And I might add that if shame is resulting because of who I am in a space, we have focused quite a bit on the who I am part. We really need to pay attention and think deeply about the space itself. And what we’re finding in this current premedical study, potentially because the participants are on the outside looking in. So we get a lot of information about their perception of the practice of medicine and of medical education, that we’re finding that there is a powerful set of expectations and standards and ultimately ideologies that govern who we are and what we do in health care and how we do it.
Will Bynum:
And these ideologies pass through certain entities and influence us as people. So, for example, we found that premed advisors are a very powerful and influential group of people when it comes to the self-assessments and self-evaluations of premedical students, because they hold a lot of power. They are gatekeepers into the world of medicine and what they tell people influences what they do in terms of their efforts to get into medical school. And we have multiple stories in this data set of students who experience profound shame when they were told by a premed or prehealth advisor, that they weren’t good enough to get into medical school, that their scores weren’t good enough, irrespective of anything else they’ve done, that because they’re from a first generation background, it’s very unlikely they would make it in the world of medicine, that because your grades aren’t good enough to be competitive you should not apply to medical school, you should go back and be a nurse.
Will Bynum:
And interestingly, many of those interactions were with students from underrepresented or marginalized backgrounds, or those who had overcome significant life adversity, like a cancer diagnosis or being an immigrant. The prehealth advisor is, we believe and our data suggests, serving as a conduit through which an ideology flows. And that ideology says that scores are the most important thing, that the MCAT is predictive of the type of physician you’re going to be, that your whatever background you bring infer some sort of expectation about how you’ll do, and then not to mention all the unconscious bias that those advisors or conduits may possess about who should be admitted into medicine and what the field should look like.
Will Bynum:
And so we’re still trying to figure this out. We’re writing the paper now and we’re grappling with sort of the weight of all this, but the role of ideologies in our cultures in propagating shame is profound and needs a lot of further study.
Joe Jackson:
I think there really are a lot of questions about how one can undo some of that ideology that is embedded within so many students’ minds. There are many learners who they are no longer accessing some of those advisors that may have told them things before that continue to shape how they make decisions going forward. So, as I advise students, it’s almost as though I’m at some level competing with voices that are now in their head even when you say you need to figure out who you are and what’s most important to you and follow your passions. What the students hear is actually I’m a number.
Joe Jackson:
This is all about a test. And even if I say something that is then different than that, what they’re still hearing is those words from a past advisor or something that they read in a website sometime before getting into medical school. So there’s a lot that has to be undone there.
Will Bynum:
Yeah, this is a great conversation. So I’m going to keep going with it. A couple thoughts. I think we’re recognizing that there may be a severe values misalignment in terms of things we value in the admissions processes into the profession, such as the incredible emphasis on scores and objective measures of performance with the values that are necessary to be an effective physician in this health care system, in this time. And when we place extreme value on objective performance in order to get into medical school that filters into the students who then place extreme value on that, because it’s necessary.
Will Bynum:
What we’re finding in our work is that they also attach their self-worth to those objective scores and to those markers, because in order to become the person that I’m hoping to become, the physician, the empath, the change agent I want to be down the road, I have to clear these hurdles, which requires certain scores and require certain behaviors to reach those scores. And so my self-worth becomes integrated with those scores.
Will Bynum:
I make a great MCAT score, I do very well on my GPA, and that makes me good enough and worthy to be in medicine. And then what we found in our other studies is that, as people go through medical school, that performance-based self-esteem can really wreak havoc on their self-evaluations and drive a lot of shame, particularly when those objective performance measures go away and we’re left with the subjective messiness of the clinical environment, yet we still need objectivity to make us feel worthy. So I think we have values misalignment here and we really need to pay attention to how we are driving contingencies of self-esteem in trainees across the spectrum of medical education.
Toni:
Are there some systems changes that could help with this? You talked about admissions. Are there other ways that maybe you’ve seen come out of some of the research to sort of better align values with what students are focusing on. And I know that’s a big question, but maybe things that you have already tried, some ways to better think about it’s not the focus always these objective measures, but other ways to kind of encourage students to think about those other things?
Will Bynum:
Joe and I are both smiling because these are the kind of questions you get when you do research like this, but you have no answers to. It’s always fun. We can definitely… Joe, you want to go first?
Joe Jackson:
Sure. Yeah, I’ve been thinking about this a lot, and I think that there are a lot of ways this could go. I think my first response is I would hate to put it on the student to be the one to sort of figure out how to be different in light of this dynamic of shame. And so actually I think first about the opportunities that we have as educators to think differently about how we create systems and programs that support our learners. And so I actually feel like there’s a huge momentum right now to talk about wellness and to talk about resilience.
Joe Jackson:
And this is just in an environment with pandemic things happening. There’s just so much where everyone is thinking about, oh, how are individuals being formed over time? But then I think when we get down to the details, it doesn’t necessarily change what we actually do in our orientation activities. So what we actually do when we first have our initial meetings with students. And so I would say that as a first place, there are the programmatic things, and even then on an individual level, being able to talk with students and getting out of the way all the things that relate to numbers and metrics, and trying to know the student, know what they’re about, focus in on their passions. And then from there building a relationship so that we can kind of talk about all these other pieces that go into being successful through their career.
Joe Jackson:
So I think for me it would be a starting place of focusing more on what we as educators can do to create an environment where our learners are more likely to thrive.
Will Bynum:
Yeah. I’m going to add just some thoughts to that that are a little different. I wholeheartedly agree with everything you just said. I think we’ve got to examine our obsession with scores and our extreme reliance on them. We can’t depart from that. We have to have ways of knowing that people are learning and that people can assimilate information and remember it and recall it, et cetera but – and I think this goes way, way deep into the education system at large – we are using scores in a way that may be very problematic, particularly at the emotional level of the individual. And one thing that we’ve been thinking about is, especially in the midst of a lot of discussions around the validity of tests like USMLE Step 1 and the MCAT, which is already generating hot debate.
Will Bynum:
One thing that’s rarely talked about is the consequential validity of these tests. So that being, what are the real world, what are the social, what are the emotional impacts of the way we’re using that test on the person who’s taking it or on the populations that are taking it? And if we look at validity through that framework, these tests are having a lot of negative effects and shame, profound shame and precarious contingencies of self-esteem are some of those effects. So I think we need to take a hard look at how we’re using scores. And then through that, we need to amplify some of the research and the piloting that’s being done around more holistic review of applicants. Making USMLE Step 1 pass-fail was a great thing. Making the MCAT pass-fail or not using it as some institutions may be doing, certainly the SAT that’s happening in certain institutions.
Will Bynum:
How can we detach from that reliance on scores to measure people? And at the same time while scores are going to remain, how do we help people detach their self-worth from those scores, at least to a degree that’s healthy? And that’s something that we can do right away. And we do that here at Duke quite a lot with our students. We really try to help them understand that they’re not defined as a global person by a number, and that they need to contextualize that number in the midst of everything else they bring to the table. But so do our admissions processes. So do our prehealth advisors. So do the people interviewing them and writing their letters of recommendation.
Will Bynum:
You have to be able to look intentionally beyond the scores to the whole person, recognizing that it’s only one measure of that person. And frankly, oftentimes an invalid one.
Joe Jackson:
I was just going to offer one addition. Will, you’ve reminded me of just this notion that when a student begins in medical school, we are very intentional about trying to think about how they’re forming over time. But this is also a reminder that we may need to give more attention to how their professional identity has actually started the formation process long before they even show up to day 1 of medical school. So there actually become then opportunities to maybe embrace our learners more with all of the baggage that they bring, all of the challenges that they faced and give some space and some room to meet them there so that they have more opportunities to form over the course of their medical career.
Will Bynum:
Yeah. And just a little preview of, I guess, our current study, the notion of self-concept has really emerged as a key structure and essence of these shame experiences and it really is across the multiple studies. And self-concept being essentially the contingencies of my self-worth, why I feel the way I do about myself, and what forms my identity, how I know myself. And we believe that the professional identity literature and discussion has largely overlooked the fundamental role of self-concept in the development and progress of a professional identity.
Will Bynum:
It also requires that when we talk about professional identity, we’re also talking about personal identity because self-concept is deeply interwoven with who we are as people and who we are as health care professionals or developing professionals. What we need to pay more attention to is as that progression and development occurs, how is the individual seeing themselves or understanding themselves as they go through a process that is actually, I think, much more dynamic than maybe prior conceptualizations of professional identity formation have been.
Toni:
Well, I want to thank you both for joining the podcast today, and I want to give you an opportunity. If you have any final thoughts you want to share, things we didn’t get a chance to talk about, maybe advice you have either for learners or for educators. I’ll give you each a chance. Joe, do you want to go first? And then Will.
Joe Jackson:
I feel like I spend quite a bit of time sharing advice, and so I always try to listen well and think about the words that can be most helpful. So I think that in this moment, as I think about the work that has been done, certainly in this paper, Shadows of Shame, and thinking about the work that’s emerging from our premedical students, I just sense that there are many learners that even though they have positive, helpful influences in their lives, guiding them in the right direction, they also have attention where there are still voices and individuals weighing on them that caused them to think less of who they are and what they are becoming. And so my advice to students would be to simply give some room for allowing yourself to think big, to think beyond your limitations, and to think less about what you don’t have and more about the opportunities before you.
Joe Jackson:
It’s a joy to sit at the sideline and see individuals who are able to set aside those barriers and constraints, because it allows them to really soar and do amazing things. And so I think that would be my best piece of advice to learners who may be listening, that if you have experienced shame, to find ways to talk about it, to find individuals that can support you in that and to at some level, try not to allow those things to keep you from really imagining and re-imagining all the things that you want to do going forward.
Joe Jackson:
And then I think that my advice for my colleagues, faculty colleagues and other medical educators who are in spaces where students are experiencing shame is simply to acknowledge out loud your own shame experiences and to find ways to normalize even more for your learners that this is something that we all experience. And I think that the more that we do that, the more room there can be to be resilient and to find ways to not be inhibited by those shame experiences, but to actually grow from them.
Will Bynum:
Well said. I have a quick shout out, a thank you, and then maybe a final thought. The shout out is to also our coauthors Lara Varpio and Pim Teunissen who are coauthors on the RIME paper. And then also our coresearchers on our current study. You couldn’t ask for a better set of mentors and advisors and friends. And they’re one of the reasons that this work has been impactful to date, one of the big reasons. The thank you is to the AAMC and Academic Medicine for just a continued platform for this topic and discussion. I’ve experienced nothing but support and opportunity to help share the importance of this topic. And it really means a lot. So Toni, thank you to you and your staff and everybody at the AAMC.
Will Bynum:
And then the final thought, I think trying to talk about shame, especially the implications of what us and others are learning in a 45-minute podcast, it’s so overwhelming and it’s overwhelming because it’s so, so complex. And it’s very hard to figure out what are the key takeaways. Because I think there’s so many. And so I think the next steps with this are: 1, to build the forums that Joe’s talking about and to facilitate them so that we can just talk about this more and be more open about it, get it on the table, and then begin grappling with what it all means. And we all have a role to play in that. The second is to attend the inherent complexity of it and recognize that we’re not going to have a list of simple solutions to this, nor should we necessarily find solutions to this.
Will Bynum:
What I do think we can do is engage in some simple actions that will begin to make an immediate difference. And that is the things that Joe was talking about, normalizing this, practicing vulnerability around this, creating safe environments where shame experiences and other challenging experiences can happen. Attending to the potential role of trauma in what we do, recognizing that the experiences of underrepresented people in medicine are much different, more challenging, and have been largely neglected from ideological norms over time. None of these require a lot of extra work. We don’t have to build curricula. We just have to start attending to them and being committed to them. So that I think we can begin doing right away. And maybe the grander interventions will emerge over time.
Toni:
I want to thank you both again for joining the podcast today. And I want to encourage listeners to look for “In the Shadow of Shame,” Will’s paper in the RIME Supplement from last year, and I’m really excited to read your premedical study when it’s ready. So thanks again for being here today.
Joe Jackson:
Thank you.
Will Bynum:
Thanks, Toni.
Toni:
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