Shame in Surgery Part 1 - The Background ===

Hello everyone. I'm Steven Thornton, a surgery resident at Duke and one of the behind the Night Surgical Education research fellows. Today I'm really excited to be bringing you a special series on shame and surgery with a particular focus on shame and surgical training. First things first. What is shame? Well, scholars conceptualize shame in a variety of ways. One way to understand it is that it is the feeling of being globally flawed, inadequate, or unworthy in BTK language. It's when you feel like you're not the kind of person who dominates the day. Does that sound relatable? I wonder how many of you listening may have felt this way about yourself while training in surgery or working as a surgeon. So why talk about shame surgeons forever

change their patient's lives? As we work to address the impact of illness, injury, and disability on the human body, we are changed too. Training and working in surgery has a profound impact on lives of the people learning and doing this craft. There is a richly documented, but in completely understood wellbeing, crisis in surgery. Rates of depression, anxiety, PTSD, suicidality and substance use disorder are all elevated. And recent evidence would suggest that the rates of each of these are higher in the period of time following a surgical complication. This problem became personal for me early in my training when one of my first mentors in surgery died by suicide. And since then. I've viewed understanding the effects of the surgical learning and working environment as among the

most pressing challenges in surgical education. Now, this problem is complex, but emotions and in particular, self-conscious emotions are one way to understand how surgeons are feeling and more specifically how they're feeling about themselves. So it's with that in mind that we're gonna dive into a multi-part series on Shame in Surgery. We're going to start with three episodes this month. In the first episode, we'll set the stage. We'll interview two experts on shame in medicine who've been studying the topic for decades. In the second and third episodes, we'll talk to the authors of recent publications and the Journal of Surgical Education, examining the relationship between shame. Burnout and grit. Then later in the year, we'll share the results of a qualitative study funded by the Association for Surgical Education,

investigating the lived experience of shame among surgical residents. Well, let's get into it. Today I'm joined by Dr. Will Bynum and Professor Luna Doza. Will and Luna are both personal mentors of mine in this space. And I couldn't be more excited to have them on the show. Will and Luna, do you mind introducing yourselves? Hi, I am Luna Dal. I'm professor of Philosophy and Medical Humanities at the University of Exeter, and I'm a shame researcher. I've been researching shame for almost 20 years, and I'm PI of the Shame and Medicine Project and with Will, I'm co-founder and co-director of the Shame Lab. I'm Will Bynum. I'm a family medicine physician and associate professor of family medicine at Duke. Uh, with you Steven. Um, I've been researching shame for almost 15 years and also have a PhD in health professions education from Morich University in the Netherlands. Really happy to be here. Well, it's, it's great to have you both on the

show. Thanks for taking the time to do this. Maybe a good place to start would just be some reflections on how you became interested in shame, and then we could dive into a little bit of detail around what shame is and how we understand it to show up in health professions. Yeah. Anyone who's ever heard me talk about shame is probably heard, you know, the, the origins of my, my interest in this topic, it, it definitely wasn't something that I, you know, sought out on my own. Nor had an innate interest in, uh, but when I was a resident, I made a medical error during a childbirth that precipitated a really intense and sort of, um, unexpected and very disorienting emotional reaction that ultimately I, I learned later as I was sort of navigating my way through that emotional experience to be the emotion of shame. Um, and, and so once I had. Kind of gone through that experience and then learned about what shame is and.

Better understood my own experiences. Through that new awareness, I then kind of went back to my learning environment and back to the medical literature and, you know, started to see shame everywhere and that led me to just start writing about it, eventually researching it. That led me to Luna. Um, and then sort of the rest is history and here we are. So for me, it came from a really deeply personal place that, you know, at a time when I was developing a real interest in. Understanding the world around me in, in sort of rigorous and new ways. Uh, Luna, what about you? Yeah, similarly, my interest in shame comes from a really personal place, but it took me many years to realize that. And I'm an academic philosopher, and when I was writing my ma and PhD, I was really interested in two fields of philosophy, phenomenology, and social constructivism, which offer differing accounts of how we are agents and subjects in the world. And when I was researching them, I saw shame as a way to link them because. In every shame experience, we have social norms which are folded into them and that sort

of shape how we experience ourselves and act in the world. So shame became this bridge to understand I guess what's commonly called in philosophy, the structure agency debate. And after about 10 years of research researching shame, I sort of realized like the reason I'm so interested in this is because. It really speaks to my experience and as a woman in late modernity and capitalist worlds with punishing beauty norms, like most women live with chronic body shame, and I certainly do and did, and it was a way for me to kind of understand. My own experience and also like looking around the experience of many people that I've come into contact with. Um, and when I was working at Trinity College, Dublin, I started working with a doctor called Barry Lyons, and he's a anesthetist, a pediatric anesthetist. And he was the one who said to me, Luna, shame is everywhere in medicine. We should research this and a project about it. And that led me to researching shame in the context of healthcare and medicine. Which was not an area that

was immediately part of my own experience, but I think we've all been patients and certainly experienced those self-conscious emotions in healthcare spaces and clinical encounters we're, and yeah, it's been a journey since then. I really appreciate you both telling me how you came to this work. Can we talk a little bit about the Shame in Medicine Project and the Shame lab? What sort of work have you guys been collaborating on in this space? I can say a little bit about the Shame in Medicine Project. That's a project I've been leading here in the UK with a collaborator in Birmingham called Matthew Gibson, who's a social scientist. He's actually a social worker who had research shame and turned his attention to research shame in medicine. So that project involved a big piece of data collection in the NHS in England looking at. Shame experiences in patients, medical students and clinicians, and we're currently writing up and publishing the findings from that data. And that project also involved a lot of humanities work. So with Will I collaborated with Will to make graphic

medicine, artwork illustrating medical students stories about shame. I've written philosophical work around forms of anticipated shame in healthcare and we've gotta. Literary study scholar looking at shame in medical memoir. So it's been a really multifaceted project looking at shame from loads of different angles and in lots of different contexts in healthcare. So we've, we've produced loads of outputs and I think Matthew has told me that the data collection we've done is the biggest study on shame that's ever been done ever anywhere. So that's really exciting to contribute such a big body of data, which is all open acts. Anyone can look at our data and use it for their own studies about healthcare in particular, and shame experiences in different populations in healthcare. The Shame in Medicine project was actually how I found Luna and I remember, you know, just kind of as in a really emerging. Scholar, if you even wanna use that term, just someone with interest in this topic and beginning to explore it. I came across shame of medicine and, and it was, I was really inspired by it, for one. I mean,

the scope of the project's impressive, the quality of the work's impressive. But it was really validating to see a group of scholars devoting real time and effort to this specific topic of shame. And it's a highly stigmatized topic, so. Even though it's sort of everywhere around us much of the time, so little direct attention is paid to it. And so it was like two ends of a magnet for Luna and I meeting through also some shared work between Duke and Exeter, and then a podcast series through the Nocturnists, which we highly recommend. It's really exceptionally well produced. And that then led us to found the Shame Lab. And the Shame Lab is a, a joint venture between the two of us, uh, our universities whereby we've. You know, it continued to advance research on shame. But where we've really invested time and energy and, and thinking is around how we operationalize and apply what we're learning about shame. It's such a applicable emotion. It gives us new ways of seeing our

world, our organizations, our relationships, our own selves, and we've really tried to harness the power of shame as a lens and as a way of solving sticky, challenging problems that have alluded us. In healthcare and beyond. So we've developed a framework that we call shame, competence, and we can talk about that throughout this conversation. And we've developed trainings and, you know, ways that people can begin engaging with shame in healthy, constructive ways, primarily at work and in professional practice. And we've just had an incredibly, you know. Uh, inspiring and worthwhile experience building the shame lab and beginning to, to see sort of the what shame can do in really constructive and positive ways in, in our work and learning. I just wanna add one thing that my welcome, uh, my Shame and Medicine project is funded by the Welcome Trust, and I really wanna acknowledge the generosity and vision of that funder to fund such a big project. And they gave us quite a lot of money to do this research on a topic that's. Quite stigmatized and taboo in healthcare generally, like when we started our project, there was

very little research looking at shame experiences, even among patients, which you would think would be an obvious area of research. Yeah, it's really great to see big organizations get behind important causes like this. You mentioned the stigmatized nature of shame and I, I guess maybe related to that, it's a word that I don't think a lot of people hear so often, even though it's something we all experience. Maybe we can just back up a couple of steps. How do you guys conceptualize shame? What is shame? Luna and I have done a lot of, I think, collaborative work and learning and brainstorming to help us develop a working definition of shame that sort of necessarily, you know, create some structure around what we're talking about when we're talking about shame, and at the same time, acknowledges. That it is a wide reaching complex phenomenon that trying to narrowly define is really tough. So I, I came to shame in my understanding

of it, primarily through kind of a more cognitive psychology lens. I really fundamentally began to understand it through a theory called Tracy and Robin's theory of self-conscious emotion. And the gist of that theory is that that shame is one of a set of self-conscious emotions that occur. In the course of a self-evaluation, so necessarily when we feel shame, we're evaluating ourselves and as a, as a part of that inward look, that self-evaluation, we activate certain ways of seeing ourselves in the current state. So often in light of a event, you know, that that triggered that self-evaluation and that self-evaluation often manifests as we fall short of a standard or an ideal. And upon realizing that we've fallen short. Of, you know, someone we're striving to be or an ideal self. We begin to see ourselves in certain ways and we compare that to the ideal. And when we fall short of that ideal, we see ourselves as further from who we're trying to be. This theory sort of pos that we feel, either shame or guilt.

Okay? So both occur upon the failure to reach an ideal and both are negatively experienced emotions. When shame predominates, we blame that shortcoming on something global and stable. Unchanging about the self. So my overall intellect, my capability, my looks, who I am as a person. So when we feel shame, we might say, I'm not good enough. I'm not talented enough, I'm not smart enough, I am bad, I'm the problem. You know, conversely, when we feel guilt, we place the blame for the, the falling short on a specific action or behavior, a tendency or a circumstance that is, you know, unstable and modifiable. Okay? And so, so shame really is a global negative attribution to the whole self. Whereby a person feels flawed, deficient and or unworthy. Now that's just one perspective through which to understand shame. Luna, pick that apart. Uh, thanks, will. So my philosophical background is phenomenology.

So, which is if you don't already know a sub-field in philosophy that's about theorizing the structures of lived experience. When you look at shame phenomenologically, you're looking at how the emotion kind of manifests when you experience it, the structures of the emotion. So shame always contains the look or gaze or perspective of another through which we see ourselves and judge ourselves. It always contains norms, social norms, standards that tell us what's appropriate or not appropriate, or normal or abnormal, good or bad. And that's the way we, we assess. Whether we fallen short in some way. And certainly shame can happen when we fall short of standards that we share with others or that we've internalized. But it can also happen when we feel like we're being treated worth, like worthless than others where we're treated as though we belong. Lower down a social hierarchy. Um, so often shame. When we've done nothing wrong, we've not actually fallen short of standards, but we're being treated as though we're falling short of standards

and experiences like discrimination and marginalization, racism, labeling, stereotyping often have in a kind of affective component that is shame. And then the thing that has fascinated me for a number of years, and I've been writing about quite a lot, is the shame we don't experience. So we often don't, you know, the reason we don't hear the word shame often is that we are so good at avoiding shame that we. That's like we're socialized to be appropriate and be normal and do everything right, that we actually are really good shame of avoiders and that's why we don't experience it. And what we often experience is the anticipation of shame. So we might anticipate that we'll be negatively judged, so we adjust our behavior. And do something different so we can avoid that shame. And so what we live with a lot of the time is not shame or embarrassment or or related emotions, but the kind of behaviors we manifest to avoid or bypass shame so that it becomes a really tricky thing to research because people then don't start to. Identify shame in their first

person experience because they've actually not experienced it. They've successfully avoided it, but shame is still organizing their behavior, still organizing their actions, and still organizing their decision making. So I think it's a really powerful way to understand shame. It's an emotion that often becomes invisible, but it's nonetheless organizing decision making and behavior. And um, and that's been a fascinating realization for me. And using resources like conceptual resources from phenomenology, my for philosophical sub-discipline to try and describe these very elusive experiences, which are nonetheless. Ubiquitous and like, there's a great article about shame in organizations called Swimming in a Sea of Shame, which I think really captures it. It's like we're all swimming in a sea of shame all the time, but it's so invisible. Like it's just the air we're breathing or the water we're in if we're fish, you know? So it's, but starting to make those experiences visible and salient is really powerful. Can I add to this? I, I

wanna just say that I think. You know, as in researching shame, the more you understand shame, the more you realize you don't know about shame, because it is just so complex, wide reaching, uniquely experienced, interwoven. One of the ways that we've grappled with that, you know, in a scholarly way and in a practical way, is to not ascribe to a single view and understanding of shame, but rather to be more inclusive of the ways that shame can be. Experienced. Right. And what that's led us to understand is that it's really is a distributed emotion. And when you look in an organization, it's an emotion that. Uniquely is experienced by individuals and some of my early understandings of shame came through that more individual level experience at the level of the self-evaluation, but it's also a relational emotion. Okay. It, you know, many scholars, and I think Lenny, you would agree, it always occurs in relation to other people. There's always a perception or a sense of negative judgment from someone else, real or. Imagined as if we're

projecting them over there and they're looking back at us and judging. It also moves among individuals. It can transfer and it often moves down hierarchies and across power structures. It's also an organizational emotion. It can become embedded in the ways we run organizations, how they're built, how they're executed, the cultures that define them, and then it's a societal level emotion. And so shame is a potent power of conformity and control, and it often filters down. Through our organizations, into our relationships and into us internalized as people from broader social norms and some of the sort of the social forces that Luna was outlining, racism, marginalism, and justice, et cetera. And then finally, it's an evolutionary emotion, and I think this is the really. This is the uplifting part of shame. If not the reassuring part is that for something that's so stigmatized and taboo and invisible and difficult to talk about, we've evolved to be able to

feel it and it's still with us for good reason. Um, it is really important in our social functioning and belonging. It's been very helpful for survival when, you know, group cohesion and cooperation was critical. And so what, when Luna and I talk about shame and we encourage people to engage more openly with it. One place we start is by acknowledging that shame. When we feel it simply humanizes us. It just means that we have an intact capacity for it. And that's a good thing. As people, we need to have that. So the experience of shame is not inherently wrong or bad, it just can become highly problematic, damaging, and destructive, you know, in, in a multitude of ways. Yeah, and just to add to that, I the, I always sort of, I love that evolutionary account shame because. One way I've heard it put is like, shame is like a, a psychological pain response. So like when you touch the fire you learn, ah, that's a bad thing. I won't do that again. And then shame acts in the same way where you, when you feel the emotion, it's a signal to you that you've done

something that's going to transgress the norms of your social group. And the social and psychological pain you feel is teaching you not to do it again because you wanna stay in your group. You don't wanna be ostracized or rejected because that will compromise survival. And the other really interesting thing is apparently humans are the only animals that have the capacity for self-conscious emotions. So this thing of like seeing yourself as though through someone else's eyes and judging yourself according to a shared standard, like other animals can't do that. Maybe higher order primates, zoologists suggests, but like what looks like shame in dogs. Katz is actually just submissive behavior. It isn't this complex self-evaluation according to external standards. So this is like a, like Will said, like a really uniquely human experience that humanizes us when we experience it and it, it, it feels bad, but actually it can have this really important pro-social function to keep us in groups, to connect us to others. There's so much richness in all of those reflections. I'm

really struck by this idea that it seems like. Shame isn't going anywhere. It's a part of what it means to be human, and certainly to be a human in the world of medicine is to encounter a lot of potential triggers for that emotion. You guys alluded to the idea of having a framework for healthy engagement with shame earlier on in the conversation, and I'm wondering if we can just talk a little bit more about that. I mean, the, and the reason it's important to talk about this, you know, just, just to kind of make sure we're anchoring this for your audience, is that, you know, shame in healthcare is, is, we would argue, is ubiquitous, you know, and we are going to experience this emotion if we have an intact capacity for self-evaluation and self-consciousness. And, and that's because we are faced every day, multiple times a day with norms and standards. Some of which are impossible to uphold consistently and that we deeply

strive to uphold, and that our identities are tightly linked to, you know, whether that's achievement or whether that's patient outcomes, or whether it's helping others, or whether it's being seen and regarded as trustworthy, responsible, good enough. There's just so many opportunities to feel shame in healthcare. That it's a real problem and huge missed opportunity, that we don't engage with it more constructively and openly, and we don't acknowledge it and even leverage it for constructive growth, belonging and connection. So that's really what underpins our, you know, sort of philosophy about shame, which is that it's both an imperative and it's an opportunity. So. In order to meet that imperative and to leverage the opportunity, we, we developed a, a framework that we call shame, competence, and shame. Competence is a set of skills and principles and practices that people can learn and that can be applied within and by individuals within teams, across organizations and broadly,

um, socially and shame competence essentially confers the ability to constructively engage with shame. In a way that leverages its pro-social potential and then mitigates its more destructive potential. And we haven't talked a lot about the destructive potential yet of shame, so we should talk about that. We talked about some of the ways shame can be good and healthy and important. We need to talk about how shame can kind of run amuck, but it's, the goal is to mitigate that destructive potential and then help us grow through shame rather than moving away from it, denying it, transferring it, et cetera. Uh, lunar, do you wanna talk about any of the, the five pillars of shame, confidence, or anything else you'd like to add? Yeah, I mean I, maybe I could pick up the bit about the destructive potential of shame and then we can come back to the five pillars. And I think like shame is characterized as a, a pro-social emotion in this kind of evolutionary psychology story about how we've evolved the capacity for shame. We evolved it so we would stay in our social groups and it ensures social cohesion and belonging and survival as a result. But

actually it's very easy for shame to be. Distorted or turn into an emotion that's very antisocial. So instead of connecting it to others, paradoxically, it disconnects us from others. And really common responses when we have a shame experience are secrecy, hiding, withdrawal avoidance. Um, and then there's a psychiatrist called Donald Nathanson who devis something called the Shame Compass, which we use a lot as a schema to explain. Defensive reactions we have to shame. So shame is such a psychologically difficult experience. It's very painful that sometimes it's intolerable and to the self and also to admit to, and that's compounded by the fact that it's taboo and stigmatized in our culture. And he schematize this, this shame compass. So it's got four points and it's kind of four patterns of behavior that we'll go to in order to deny shame either to ourselves or to others, or to bypass shame. There are things like once you start thinking about it, it's kind of obvious, but things like attack others. So you feel shame and you

lash out at someone else and that's the way to discharge your negative feeling elsewhere, um, or attack self. And he talks about withdrawal and also denial. We've kind of modified the compass to also to include compensate. So those are behaviors that actually look really good from the outside. So like perfectionism, overachievement, you know, overworking po positivity that's verging on the toxic positivity. Um, where you, and I think Brene Brown's quote about perfectionism is really, um, useful to understand this. Where she says perfectionism is this kind of belief system that if I. I am totally perfect and do everything perfectly. I can always stay two steps ahead of shame, so no one can ever say that you're not good enough or you're flawed. And I think that resonates with a healthcare professionals community, where you're held up to high standards, and maybe it's a profession that attracts high achieving perfectionists, and you don't think about shame being part of that picture. But actually, if you start to see it through the shame lens, you think, well actually, what? What are you running? What are you trying to stay two steps

ahead from, and what are you protecting yourself from with this kind of behavior and perfectionism and overachievement? Look positive on the outside, but actually can be antisocial behaviors. You might end up being a very judgmental person, distancing yourself from others working so much, you don't actually have any connections with others. And it's really important to recognize the anti-social potential of shame through things like defensive or behaviors, lashing out, withdrawing and avoiding. Situations are from others. And that's precisely like shame is normal and inevitable, but those anti-social aspects of shame aren't, we can work to make them more pro-social and constructive. Shame can also be, you know, utilized. You know, there's shaming, which is behavior that causes another person to feel shame. And I think, you know, medicine and medical education, healthcare have a, a deeply embedded. Shaming problem. Um, I think whether well-intentioned or not,

uh, the act of causing another person to feel shame in order to change a behavior, in order to teach, in order to, you know, drive competence is generally accepted and put in a practice. And I think often mindlessly when we think about the self-conscious effects of that. Which are often not going to be known because shame sort of goes into hiding and it offers an experienced in, you know, underground. So not only is shame or do we live in sort of a high risk shame environment in medicine, you know, we we're striving for ideals that cannot be attained without a lot of struggle and without a lot of failure and without a lot of growth. We're, you know, navigating norms and standards every day in the work we do and shame circulates in our environments, and it is utilized as, as a tool. And so we have a shame. Well, we, we used to say, I, I used to really say we have a real shame problem in healthcare. I think we still, we, we have some shame problems. I think we also have a lot of shame

opportunities. And, and so that, that, that's why we need a more of a collective ability to understand shame, to acknowledge that it exists, to recognize that, to respond to it, to avoid shaming, and then to to transform organizations. And those are the five pillars of shame. Competence. I wanna talk more about shaming behavior. I, I think. As you alluded to, will, this is something that is really widely accepted in medicine as a norm of the training experience. But there's, there's some people who reject it as appropriate and would say This is not a good way to go about teaching people to become doctors, or in the case of our audience teaching and training people to become surgeons. What is the, the risk of causing shame in other people? If, if you recognize that it's a bad thing and you don't wanna shame others, or are you sort of protected from that possibility? Or is this something that you can like, kind

of put your foot in your mouth and, and do accidentally? Yeah. Well, we, we've, we, I won't go into detail about it, but we've talked about and, and theorized multiple different types of shaming. You know, not, not all shaming is equal. Really where it breaks down is, is along the lines of intent and then awareness of, you know, the potential for shame. You know, when we're aware of what shame is and our intention is to make someone feel shame or to put them in a lower position, we would consider that to be intentional shaming and. That intent isn't always bad. I mean, shaming you with the intent of teaching you or driving accountability or making sure you never do this again. You never make this misstep in an operation. You never, you know, fail to follow up on this critical lab that the intent is, I'm, I'm gonna make you feel something. So significant emotionally that you'll never forget this. And there's also often a mis, I think, conception, but a belief that the only way that I, I

can ensure that you'll feel and be accountable to this behavior is to make you feel badly about yourself. Right? And then that bad feeling, and you showing me that you feel bad about yourself, helps me ensure that you're feeling accountability. I think we've equated shame and accountability, um, in many ways. Shame can also be, you know, intentionally levied just to make someone else feel bad about themselves so I can feel better about myself, right? If I'm getting berated by the, the person above me in the hierarchy, and you're the person below me, and I just turn that berate to you and make you feel bad about yourself, it might be being done so that I can recollect a sense of self, recollect, a sense of power, having lost it. In this other interaction on the other end of that spectrum is, is what we would consider maybe sort of incidental or accidental shaming, which is really where I'm. More or less not very shame aware. I'm really not aware of how my behaviors are affecting you and the potential for shame, and I'm not really intending to make you feel shame and yet you're feeling it

anyway. Right. And, and in the purest form of accidental shaming, this is when we do sort of everything, right? We might deliver difficult feedback in a way that's specific, timely, shown with care and compassion. And based on my direct observation. Right, and you receive that information and you still feel badly about yourself, you still feel like you're not good enough, unworthy, a loss of reputation, et cetera. And then there's what we, we consider sort of more mindless shaming, which is, I'm really not intending to make you feel shame. I'm just not aware of the likelihood of my behaviors doing that. And this, the classic one of this is just pimping or, you know, questioning to the point of. You know, you just breaking down and not knowing anymore and often to the point of humiliation or feeling exposed. That practice, even when it's not done with the intention of making you feel that way, can induce shame. It's highly public. It often reveals knowledge deficits, and it can feel very sort of, um, you can feel very singled out in front of other people. So the likelihood of shame is there. The awareness that the potential for that shame is

often not. So we all have inherent capacity to cause other people to feel shame. And the work that, and the way we've done it and the way I've done it and seen it in healthcare, the higher your position, you the sort of, the more years under your belt, the wider your skin. And if you have a Y chromosome, I think you're more likely, increasingly to cause shame for other people. And so we have to recognize that inherent capacity and the intersectionality, you know, across which it, it develops. Luna, do you wanna add anything to that? Yeah, I mean, thank you. That's a really brilliant summary of like the different ways it's so complex. Um, but I think the other thing to add is that like. You don't actually even need people for shaming to happen. Like it's sometimes just baked into the institutions. And like examples that have been given to me are like someone with a larger body going to a clinic and there are no chairs that they can sit in. And like that is a humiliating experience because the space, the material environment is set up to give them the message that they don't

fit in and they don't belong. Or a, a medical student with a larger body who can't find scrubs in a hospital that. Fit their body and lots of examples of, you know, from the patient side. A person gave me an example of her mom going to hospital to get a scan. She had to change into a hospital gown with an open back and did that in one room, but then had to walk through the public cafeteria to get to the room with the scanning machine and found that humiliating. And obviously there's no one person who's trying to shame or embarrass anyone, but it's just no one's really thought through the emotional consequences of, uh, of the flow of a procedure or. Going to a clinic where you have to disclose something sensitive to a receptionist, but everyone sitting there can hear what you're saying. And those experiences mean that someone might never go back to that clinic or might, you know, might never attend again, or might just be, you know, left with trauma or emotional distress after an experience. So. One of the things we teach through shame, competence is like being able to recognize the shaming. That's like literally like baked into the institution. You know,

it becomes part of the wall, the wallpaper, and you don't even notice it's there. But once you see it, you can't unsee it. And it's often around privacy exposure, not feeling respected, not feeling like you belong or fit in because things aren't accommodating for you. And yeah, so that, that's been like a really interesting aspect to understanding shaming as well. Yeah, I would love to build on that for a moment, just. Just in particular through my experiences in healthcare, other places where shame becomes really deeply embedded organizationally, as in, in our culture, how do we talk to one another? What's the tone of voice we use? How do we, you know, respond when we fall short? When, when things get stressful, how are we communicating with one another? Our practices, how do we formally communicate? You know, when you work in, or, or educated by or within an institution that's a top five institution in some way, and the institution keeps talking about how top five they are. There's people out there. Especially on days where

they're struggling thinking, I'm not a top five person, I'm not a top five resident, and I'm letting this institution down. How can I ever meet the standard that's being expressed by that? You know? Or when a med school publishes their rank list, you know, the end of match day and says, our students matched into these top eight programs, you know, and they list all the programs and they, and then they say plus 40 others. What if you match into one of those other 40 programs? Right. How does that make you feel about yourself? Shaming is baked into our cultures, our practices, our policies. How do we do remediation? How do we do morbidity? Mortality conference, right? How do we onboard people? How do we orient them? When someone comes to our rotation for the first time, is there a place for them to sit? Is anybody calling them by their name? Are they just the med student? Right? I mean, all of these are part and parcel of the way our organizations run often. Ideologically and insidiously that have real shame potential. And, and that's where the shame lens becomes so powerful because once you start looking

through that lens, you start to see these things and then you can start to change them for the better of everybody. And just to come in on that. And I think that's like why when you, uh, going back to Will's discussion of the distributed nature of shame, when you're teaching shame competent, it's not. It's not just teaching frontline professionals how to notice shame in their colleagues or in their clients or patients or service users, but it's actually like an organizational thing. Like what are the HR policies here? What is the culture here? What are the practices? What are the material conditions? What do waiting rooms look like? You know, it's like everything and you have to look at it through that organizational lens. Otherwise you're just sort of tinkering on the surface. And what we're really looking at. It. Yes, we're thinking about this through the lens of shame, but really what we're looking at is how do people feel about themselves when they come to work, when they learn, when we teach them, when we give them feedback. And it, what's so mind blowing sometimes, and I've been a, I was as aloof as anybody to this is that we don't attend to that. That's a, that

is a core aspect of the human experience, how we feel about ourselves and yet we attend to that. So tangentially, if at all that what, what. What the shame lens does, what shame incompetence does, what talking about shame does more so than shame. It just centers us on what is it like to be a self-conscious person in our environments? And if we can attend to that, I think we finally get down to some of the basement level of what it means to be a human in a space. And we build up from there. And I think that starts to help us solve problems that to date have been really, really hard to solve because we haven't been working at the right level. Yeah. Let's, let's talk some more about that. So. I'm struck by how you guys are describing this distributed nature of shame. There's like the part that I think probably feels most salient, which is the cognitive psychology piece. This self-evaluation falling short of a a norm. There's a ton of perfectionism in medicine writ large, and certainly within surgery specifically.

But there's also these higher, more abstract, in some ways, planes on which shame is operating. So what are we meant to do with this information? Once we acknowledge shame and we develop a capacity to recognize it, how should we be treating ourselves and how should we be treating other people knowing that we are in a culture where shame is baked into the experience? Oh, I can start to think about that. I mean, I think the first. Step is awareness, and that is like the antisocial potential and shame is intensified by its taboo nature. So when we don't talk about it, we keep it secret. So as the, you know, the distributed nature of shame, like the first layer of that is. I am an individual and I'm having a shame, emotional experience. So, and then, then the next layer is it's a relational experience. It's moving between people and then it's framed by social norms and standards and

then it's embedded in organizations. And all of that is framed by our kind of the evolutionary story about why we have shame in the first place. So like things like being able, when you're having a shame experience, being able to turn to a trusted colleague or friend and express that. That can be hugely cathartic and transformational. And then you have a connection because they might say, well, you know what, I felt that too. Or they might be able to like, you know, talk you down from the experience and just being able to speak openly about this, these experiences as we're having them on an individual level or relationally, can make a huge difference in terms of their, like diffusing the anti-social potential and starting to kind of activate the pro-social potential, which is like connection, belonging. Authentic emotional expression, authentic expression in general. Then, I mean, this is really hard thing to do in organizations that are intensely hierarchical and there are consequences for stepping out of line that like being able to recognize when shaming is happening and also being able to

recognize where it's coming from. So if someone's shaming you, they're probably having a bad day or they're, they're trying to discharge some of their own emotional distress. And you just happen to be the person in the firing line and that way of like creating a little bit of separation. It's not about me being terrible or bad actually. Maybe they've got something going on and maybe that's why they're behaving unprofessionally or inappropriately. And being able to recognize like how shaming and blaming and anger and aggression or actually ashamed defense can also help just create that little bit of space. So the reaction can be empathy rather than. Distress about how one's being treated and it's easy to theorize this and talk about it, but all of these kind of cognitive learnings can create little bits of space in our emotional responses. And I mean, there's way more I could say, but Will do you wanna come? Yeah, it's great. I mean, it's a big question and there's a, you know, entire training programs we're trying to build to answer it and that others are building.

One thing I wanna say, maybe even more foundationally to the is how we, I think we need to conceptualize the role of shame and its existence and our, our, you know, mutual, all of us, our role in upholding, shaming, I mean, we are all have a role in upholding these structures every day. If we come at this by saying shame is a, a massive problem that has to be solved and eradicated. Kind of like we've done with some other, you know, constructs like burnout and things like that, then, then not only is that gonna be potentially more harmful, but it's gonna miss a lot of opportunity through collective understanding, humanization empathy that shame can bring with it. So one of the reasons I say that is that it's very easy when you begin to understand how shaming occurs and you begin to see your role in propagating shaming behavior to have a shame experience because of that. Right? Oh my god. Now I start to see myself as falling far short of a

standard. I'm shaming other people and I've seen it firsthand. The defensiveness that can cause it can cause people to shut down to retreat, and then shame becomes just as sort of nuclear and and toxic as it has been all along, right? What we have to do is approach this with acceptance, with curiosity, with recognition that it's just a fundamental human emotion that yes, can be problematic, but is not inherently bad. So there's gotta be a collective. Empathy and love around this self-love and love for each other in order to really grapple with this emotion because it's gonna make us see ourselves in ways that aren't super flattering sometimes, and we have to be able to confront those and try to be better. The second thing is I think we have to attach this work to our deeper values. This is not about, this is not about addressing shame. What this is fundamentally about is humanizing people. It's about upholding our fundamental need to feel good enough and feel worthy and to belong in spaces, you know, and, and to feel like we're

cared for and loved. I mean, these are fundamental human needs We have. On which development of medical competence and procedural skill and you know, all the different socialization that's required for medicine on which that builds. So really it's about going deeply back to basics and supporting the fundamental needs we have as people. And we can do that by attending to shame. Okay? And so that's where it starts. So then that's where acknowledgement and awareness of shame, having kind of shared literacy about what it is, how to maybe recognize when it might be present. And certainly I recognize our role in propagating it. And then, and, and there's all sorts of strategies that, that we can learn to do that, like actually do that in a real relationship or a real interaction or self. Guided process, and we don't have time to talk about all those. But those skills can be learned, but they have to be connected to this deeper commitment to supporting people in the ways they need to be supported. And that's why shame is important. And just to add to that, like those skills can be

learned and you don't need to be a psychotherapist or someone working in the psycho. Psychology or psychotherapeutic, you know, field to learn those skills. Like these are practical things as humans that we can understand, like through some psychoeducation. And then like really practical skills. You know, responding to someone who's experiencing shame, like you can just learn the right things to say, the sort of body language to adopt, you know, they're very practical skills and practices that anyone can understand and learn. It sounds like that might make for another good follow up episode we can talk about. Getting into the details of, of how to respond to your shame and other people's shame, a, as we sort of come to the end of our time, I wanted to give you guys the opportunity, if there's anything else about the shame lab or your work in this space that thinks important for our listeners to hear as we dive into a series on shame and surgery. I don't really have a lot to say about, you know, the shame lab in our work. We really appreciate the platform to

share some of this. I think what I'll maybe wanna just emphasize is that how important and motivating and even inspiring it's been at times, seeing the uptake of this. This topic and, you know, all dimensions of it. Painful, emotive, challenging in, in healthcare. I mean, we have so much work to do and so much work that we can do, but it's really, it's, you know, the fact that we're on this podcast talking about this, I've done some really meaningful work with, you know, your department, uh, other surgical departments at Duke and, you know, and other, other places. Some of the places where shame. Not just in surgery, but where shame really has become deeply embedded and there's a real desire and motivation to, to begin leveraging that and doing something about it. I think the only way that we kind of hit that. The deeper sort of work that we want to do in humanizing ourselves and taking care of ourselves. The only

way we can fully achieve that is by going head first into this emotion. And we have to, and, and I don't mean like kamikaze head first. I mean deliberately, intentionally with awareness, with kind of equipped with some of those, you know, ways of humanizing ourselves and seeing one another that sometimes is so lacking in healthcare. I mean, it, it really can be a revolutionary thing. So in order to do that though, we have to develop some broader shared understandings of this and, and what it means and what it can mean and, you know, to have the chance to do that on this, this podcast. We're really grateful and we, we appreciate your advocacy in that regard. Yeah, and just to follow on from Will, I think that's also something that's really struck me in my years of researching shame in medicine is like once people understand the shame construct or concept, it's kinda like, oh yeah, now I get why it's so relevant and. There's just such a. Deep understanding of why we need to understand this, and that's really inspiring to see people having really transformational

experiences around this self understanding and then really understanding their role as a healthcare provider and how impactful it can be. To just really just teach people some basic stuff about shame something, and it's also you're teaching them something they kind of know on some level. So it's like you're just putting words around things that are already being experienced, and that's really rewarding as well. So, yeah, thank you Stephen, for engaging with us and our work. To that end, I mean, I, I, I might, you know, just suggest there's so much more to talk about with shame. There's so much more to do with it. But one of the best places to start if you're listening, is just to spend a little time reflecting on, you know, your experiences of how you know yourself and feel about yourself. Do it in a way that's safe. Do it in a way that's measured and, and supported. And then if and when the opportunity presents, just start a conversation about it. I mean. The more we just start talking about this emotion, the more we normalize it and the more acceptable it becomes, the more we learn about each other, and the more then we can see our world through the lens

that these emotions present. So yeah, just start talking about it and you know, I, I'll tell you if you, if you ever don't know who to talk to about it, Stephen Thornton is a great person. He is. He's got all the right sort of approaches and characteristics and character traits of to talking about shame. So if you need someone to talk to and you're not sure who, Steven, I'm just gonna put you out there. You'd be a great resource. Will and Luna, thanks so much for coming on the show. It's been a privilege as always to talk to you both and learn from your expertise in this area. Really appreciate you. Thank you. Thanks for having us. Thank you all.