Shame in Surgery Part 2 - Grit, Shame, Burnout ===

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 to 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 while being 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. 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. This is the second episode in that series. If you missed the first one, I recommend pausing here. Go back and check out that episode in it. We set the stage for this series. We'll wait for you here. For those who are tuning back in, let's get into it. I'm joined

by Dr. Dino Za and Dr. Wan Elop, both from McGill University, Dr. Zammit, and thanks for coming on the show. Thanks for having us. Happy to be here. So tell me a little bit about where you're at in your careers, Dr. Ela. So, uh, I'm currently the chief resident PGY four at Miguel, university of Plastic Surgery Residency Program. Dr. Zammit? Yeah, so I'm one of the staff physicians here at our, uh, children's and Trauma Center. I'm currently the program director as of, uh, June of this year. And I have a specialty training in, uh, cranial maxillofacial surgery. It's really great to have both of you on the show. Can you tell our listeners a little bit about what got you interested in studying shame in surgical education? So I guess from a resident perspective as you know, as surgical residents, we were teacher in different services and very early on I noticed very different surgical culture and East Surgical specialty have gone through. And I've noticed that my

program was very, very active in promoting cultural wellness and inclusivity. And I've noticed it would be interesting to study the differences between surgical specialties in terms of surgical education culture, and our aim was also to check other provinces and check if the surgical experience is different areas. And what about from the faculty perspective? What sparked your interest, Dr. Sam? So I'd have to say I, it probably starts from where I come from as in terms of background of growing up, playing a lot of sports. And for, for anyone who plays sports, I think, you know, kind of, it wouldn't be shame-based learning, but kind of shame-based practice was how you got better and how you kind of took yourself to the next level. So that was a culture that I always grew up in playing, uh, you know, sports at a, at a higher level, and then. Having been at McGill, you know, for my undergrad, for my medical school, for my residency, again, I, I saw early on, probably near the end of the last

cohort of, you know, students and trainees who was really exposed to shame-based learning, and that was kind of the norm. Remember, as you know, early resident residency. Getting scolded by the senior resident for speaking to a staff. Whereas now, you know, being a staff, being a program director, I routinely will have conversations with medical students, with the juniors. You know, I'll get updates from the juniors without even thinking say, oh, this should have came from the senior. Uh, so I think really seeing that shift and from when I was a student to now as a staff and how just the different generations respond differently to criticism, feedback, instruction. I think when, when, uh, Roan brought this idea to me, I thought it, it would be a great to look at it again, compare the different specialties, different programs, different provinces to see where, where everyone's at today. If I'm hearing you correctly, it sounds like you both had a really strong interest in understanding the culture of surgical training and shame was one lens through which you thought you'd be able to do that. Am I hearing you correctly? And interest?

Mainly focused also on. Us noticing that the surgical training is actively being changed. I'll speak specifically about Canada and specifically about Miguel, specifically about my plastic surgery training program. There we've noticed, uh, great shift, like even before. It's very different than when I came in as an R one. It's really improving. So it, it, it just was like some food for thought, uh, for thought to see how, uh, things are being and to have a, a baseline to compare to in the future. And I think as well too is that, you know, especially be, you know, being put in this leadership role is that you realize that not everyone responds the same. Way of training. Whereas yes, some may, may need to be called out, may need to be pushed further, but you can't use that recipe across all trainees. I really appreciate those reflections and I applaud you guys

for using your own institution as a study ground for this important topic. I want to talk a little bit more about your specific study. I know there's a lot of definitions involved in work that seeks to understand the culture of a workplace. Maybe we could start off with some definitions. Help our listeners understand what exactly we're talking about with shame-based learning, burnout, grit. Perfect. So our study was really like investigating the association of grit and shame-based learning on burnout and surgical training. And to, to really speak about that. We need to, we did provide, uh, definitions to our participants. So what is shaming? Shaming and surgical training really refers to use the use of humiliation, belittlement or atory remarks towards surgical trainees. So some people see it as a form of feedback, but if I would people, like people understand it better when it's given an example. So if, if I, if a trainee does a mistake or a medical

error, they're really two different, two different ways to get around it when you're giving feedback and if, if an error is committed, it has to be addressed. So it's really different when you say to your resident or your junior resident, this is a mistake, this, this is something that would adversely affect patient care. You cannot do something like that. It has to be done this way. This is not something that we can accept. It's different. It's different. When you say it's in a different tone and you go like, what were you thinking? A kindergarten student? Wouldn't commit an error like that when I was at your stage. I've never done anything like that. So both feedback mechanisms deliver a message, but the way you say it, whether it has some shaming attributes to it or not, is different. So this is shaming. We also discussed burnout. So

burnout is a more commonly accepted or easy to understand term, and it's really a state of emotional exhaustion, deeper depersonalization or reduced personal accomplishments that people could go through after going through very stressful situations. We did assess burnout using a validated score, and we did also check. Association of grit with shame-based learning and burnout and grit is a very interesting thing to discuss because it's really a, a trait that people think might, might be something that you're born with. You can't attain it. It's a trait that you would select candidates in the interview process that have, and others think that you can train to be more gritty. And grit really means like perseverance. Strength of character and passion for long-term, long-term goals that can't be dampen. So these are mainly the definitions that we try to, uh, discuss in our paper.

I really appreciate that. It sounds like in this study, when it comes to shame, you're really interested in this idea of going out of your way to shame or humiliate a learner, and I applaud you for connecting it to well accepted constructs, both in the. Surgical literature, but also the workplace literature and the psychology literature. I think connecting shame with grit and with burnout is real strength of this study. I'd like to dive into the details a little bit more. Can you tell us what you were hoping to learn and how you went about designing this project? So as discussed, we historically, the educational culture of surgical training in engraved over the years really emphasized perfect and imperfections were historically are still until today, uh, being addressed by. Blaming and shame and proponents of shame-based learning argue that it actually motivates trainees to work harder and avoid mistakes and be tougher and be stronger.

But in reality, accumulating research is showing that it really has the opposite effect rather than inspiring improvement. It inhibits learning and it creates an environment where residents really fear failure, fear asking questions, fear, putting their best foot forward, and are more. Consumed by anxiety or more consumed by having to go around to avoid being shamed or being attacked. So what we did is we did the designed the cross-sectional study in May, 2024 that had validated questionnaires to assess the outcomes that we just discussed, and it was distributed across different surgical specialties in Miguel. We had a total of, uh, 76 residents responding, which is 35% response rate, uh, from all surgical specialties. Can you tell us a little bit more about what you found? Of course. So our study found that,

in fact, 75% of residents reported being personally shamed and nearly 90% had seen a staff shame, a resident, most shaming in fact. From our study, uh, was reported to be by attending surgeons in 93%, or senior residents, 61%, or even nurses in 40% of the cases. It most often occurred in the operating room, but it also happened on the floor, and the biggest trigger for being shamed was giving a wrong answer. Half of the cases are following disagreements in patient care or circular error. I have to say that it was interesting to find that. 16% of the residents said that they were being shamed, but they didn't know why they were being shamed. Yeah. That's particularly striking to me. I mean, not withstanding the fact that it seems like shame-based learning is an ineffective approach to education. Even if you were to

argue that you were trying to teach someone by shaming them, if they don't understand why they're being shamed, what in the world are they supposed to learn from it? So the other thing I'm wondering, you know, this experience seems so prevalent for the trainees in your study. Can you tell us about the consequences of shaming for the participants that you were working with? Of course. So the impact was really significant. Shaming was linked to, uh, residents reporting, loss of self-confidence, 63% depression or anxiety in 40%. Professional isolation in 30% and poor job performance in 30%. So trainers use shame-based learning to make you better. However, residents reported poor job performance. 4% of the residents actually also reported suicidal thoughts in the past year because of the influence of shame-based learning and burnout. How did the

residents in your study cope with all of this? So most residents actually kept it to themselves. That's two thirds of the study population. And it really shows how isolating this can be. Importantly, shame-based learning was also statistically associated with higher burnout scores and lower professional fulfillment. So your study uses this phrase, shame-based learning. Do you have a sense of if all of the shaming that the trainees encountered during this study. Was in fact geared towards their learning. Albeit it sounds an ineffective strategy toward achieving that goal. Yeah, I agree that it wouldn't be really towards their learning, but more towards a reflection and kind of almost scare them into not messing up again. So in fact, they weren't really learning anything, is the only thing that we're learning is that, oh, I can't screw this up. And it, you know, really has nothing to do about the scenario that happened. And I think, you know, as we. Look at this in greater detail. Uh, we realize that we can't, you know, one, we shouldn't be

shaming. And as I mentioned that everyone has a different learning. No way to learn. So I think it's not really a shame-based learning. It's really a shame-based reflection, really just to kind of scare the trainee. What are your thoughts around the intentionality of shaming? Do you imagine that most of the shame that residents encountered was inflicted intentionally, or. Almost accidentally. I think it really depends on the scenario. You know, as surgeons we deal with high, some high stress situations. So I think in situations where you know, there potentially something really, you know, significant could happen in terms of outcomes, it may almost be reactionary. But I also believe there are instances where it's purposefully done to really kind of. You know, lower the steam and really, you know, drill it into the train's head that, you know, as the staff you're more superior, you know, more, uh, almost like, you know, this God complex. So I, I do think there are two different scenarios that sometimes it is reactive just because of the high stress station of what

we do. The results of your study are really sobering. To me, the profound negative impact that shaming has on surgical trainees is so striking. I'm wondering if you noticed any differences across demographics within your study, differences across training levels, training paradigms, gender, racial identity. How did these things intersect with shame? That's a very good question. We did investigate that and we found that demographics didn't really predict burnout, grit. However, females were more likely the males to believe that shaming was necessary for training in their field. We're not sure why this was the case, but in, in our paper, we, we didn't really find that females reported higher burnout or being shamed more often, or the, they basically, it, it was not gender, was not associated with the outcomes. Another surprising finding we had was that shaming wasn't

always hierarchical, which means that 13%. Of the residents actually reported being shamed by more Joi, more junior trainees, which really raises new questions about how culture spreads within a team. Yeah, that's really fascinating. So what do you make of those observations in particular? I'm interested in the female residents being more likely to believe that shaming was necessary, but also that shaming wasn't always hierarchical. I feel like classically, when I think of shame experiences. I think of being on the bottom side of a power dynamic. But it sounds like that wasn't always the case for this study. It was surprising to us as well. But it's all falling back to the concept that it's really a culture that you're trying to cu cu like to build within your team. And what you model gets mirrored back, right? So if the culture is.

Focus on shame-based learning and atory remarks. Uh, it's not surprising that more junior team members would be using the same method of responding back. I know you guys wrote in the paper about the difference between the extent to which female versus male residents thought that shaming was ever necessary or appropriate. Is that something that you have thoughts on? Again, this is not supported by data. 'cause we did not dig deep into why females would think shame-based learning is necessary in training more often than males. I think it just goes back to personally, maybe they try to put their best foot forward and toughen up. Given this is the expectation to be in a high stressful, uh, learning environment. But personally, I'm. It would be interesting to study why that, uh, would be the case. I'm not

really sure. Yeah, I imagine it's intensely personal and varies for different people. I wonder if it's the kind of thing that a qualitative investigation might help to elucidate. Yes, exactly. And the focus of our paper was more of the surgical culture and how it's more than, um. Gender relationships. So it would be an interesting topic for other researchers who are, are studying that. So I already mentioned this once, but one of the real strengths that I see in your work is that you correlated shame, which is a relatively novel way of trying to understand the culture of surgical training with more well-established constructs. One of them was grit. Can you tell us a little bit more about how GRIT played into your finding? So we wanted to see if there were any protective factors

to arm the residents from the negative influences of training in a high stressful environment. And for that we added grit. We also added marital status like uh, support from other sources. And we did find that grit is really protective. So residents with higher grid scores and we measured grid by a validated scale, were less likely to report burnout, and they actually reported greater professional fulfillment. Interestingly, gritty residents, if we say were also likely, were less likely to shame others. So it suggests the cycle where resilience supports positive behavior and positive behavior reduces burnout. It's important to note though. That higher burnout scores were associated with thoughts of suicide, irrespective of grit level. What does that mean?

It means that if a, if a resident has high grit, and they did really go through a very tough to the point that they were really burnt out at this point, the grit is not a protective for them. They still had thoughts of suicide. I'm really struck by this idea. Not only was grit protective for the individual's experience of shame, but it sounds like it was also a mediating factor in whether or not they were prone to shame other people. And it makes me think of a concept I've encountered in the psychology literature around shame, called the shame compass, which describes a common reaction to shame. Being attacking other people. And in your paper you sort of write about this through the lens of a a virtuous cycle where people who are doing well

are less likely to treat other people poorly. And people who are doing poorly are more likely to treat other people poorly. It really makes me wonder if some of the people who are inflicting this shame are just. Trying to deal with their own difficult emotional experiences, whether they be shame-based or, or otherwise, maybe they're just lashing out. Sublimating, what are your thoughts? Yeah, I, I think it's, you know, definitely something to take into consideration. I mean, you don't know what, what anyone's going through on a given day, and, you know, I've, I've seen it just in my own experience, something. Very minute can set someone off and that same person, you know, there could be a more, you know, a bigger mistake or or error that was done where it was taken a lot lightly. So I definitely think that would play a role and I'm not, you know, not surprised of hearing that. Also,

we tend to mirror again what we've been through. So if. For example, a certain, uh, attending have been training in a certain way for so long. It's just the way of responding to certain situations is, uh, it usually gets repeated. So that's why when we discuss this with different staff and attendings and there isn't a lot of awareness on the impact of. Machine based learning on resins, there's a common thought that we're making you tougher. It's the results of the research that's saying that it's actually detrimental. So having discussions like these would actually shed the light on that and help programs and surgical, uh, trainers work more on, uh, studying how to give. Constructive feedback. Yeah, that totally makes sense. And it resonates

with my experience as well. I feel like I've heard so many people, trainees, faculty alike, say things to the effect of, surgery is really hard. We can't make the training easy. But that doesn't quite seem like what we're talking about here. It doesn't seem like we're advocating for making the training easy. It seems like we're advocating for finding strategies. To engage in ways that are productive, ways that lead trainees to dig in their heels and to engage with the difficulties of being a surgeon in training. Dr. Zimmet, I'm curious, your perspective as a program director, how do you see the culture shifting around the topic of shame and toughness? Yeah, I think it's definitely shifted over the years. You know, historically we associated. Humiliation with toughening, uh, surgical trainee. And as you mentioned, surgery is hard, but I think as time

goes on, realize that, you know, over time this humiliation, this shaming, you know, can really affect the performance of a resident and that performance can directly impact. One, their wellbeing and also patient safety and patient outcomes. If they're not able to give a hundred percent, because there's a constant thought of fear of, uh, being reprimanded. You know, they can't give their all and they can't treat the patient as they should. Again, I think as we, you know, as, as time goes on and there's, you know, different, just a different generation, I think we have to be mindful again of. Different trainees may require different forms of training and I think that's something that's becoming more and more apparent in the literature and, and even just in my experience, I know there's some residents I can be a bit tougher with, you know, just 'cause of that relationship I have with them and others, you know, even if it's the same error at the same level. I know I have to kind of

give that feedback and that kind of criticism in a different way. I may have to be a more gentler, but at the same time. Those two different residents, even though they're given a different form of feedback if it's tailored to them, will actually increase their performance and they'll do a better job after. And that's the goal, right? Surgery is really hard. I love that there are faculty who are spending their time thinking about what we can do to create a culture where trainees are supported in. Rising to meet the moment and to engaging with those difficulties of surgery. So this is a great study and it answers some important questions. It also brings up a lot of new questions. Can you both tell me a little bit about where you want to take your research from here? I think the next step is kind of like what I've been saying, uh, you know, throughout our discussion is really focus on what are the different

forms of. Feedback and, and training. We need to tailor based off who the trainee is and really focusing on looking at kind of trainee specific approaches on their training and on feedback. I agree. And we did discuss, and our, our program again, is very active with constructive feedback training and everyone in the team should really know that. They're really a model of respect and professionalism. Uh, people look up to us and, uh, junior residents, medical students, and it's really important that residents also take charge and accountability of the errors or the shortcomings that come through from them. There should be self-reflection. There should be accountability because when someone is not owning up to, their performance. So this could really trigger a more tough approach to feedback.

It's very, also, it's really important to promote a culture of psychological safety and change really requires leadership. Individuals on a higher hierarchy level usually have higher power to implement change. So the people surrounding the situation of shaming the witnesses, everyone is really. To point something out if it's not being done well. And again, there's always ways to go around to promote that. Some people don't like confrontation, so there is anonymous reporting. It remains to be a safe option if it's clearly delineated within the, within a program, and just to end it positively with all that being experienced. Almost 80% of our surgical residents that we sampled reported they're satisfied to, very satisfied for having a chance to even becoming a surgeon. So there is a clear passion for the carrier, and we just want to promote a better

surgical educational culture. So everyone is giving their best and patient outcomes are being delivered effectively. That's such a powerful message, and I really like the emphasis on how special of a career path this is. There's really nothing better. I mean, if you get to have your impact through a career in medicine in the operating room, I think that is such a privileged position and such a special role to get to play in a patient's life. As we come toward the end of our time together on the show today, what are some quick hits that you want our listeners to take away from your study? Yeah, so just getting back to culture shift, I think, you know, as I mentioned, being here from a student all the way to now as a staff and seeing the shift in culture. I think when I first started, a lot of the staff were from that older generation where it was, you know, I was shamed, I was humiliated, and now I'm gonna. Put that on view. Whereas now a lot of our

staff are kind of in the early to mid stages of their career. So on the relatively newer spectrum where again, I think with just. Globally, the shift in the way people are treated, uh, has really had a big impact on our situation here and the training that we get in terms of that humiliation and shame versus, you know, really a constructive. Feedback, which again, it's not to say that if someone makes a mistake or does an error, that shouldn't be brought to their attention. But as Rwanda mentioned, I think it's all in the tone. You deliver it, and I think being able to identify which residents may respond to a more. They say aggressive tone, but a more direct tone versus others that you may have to kind of soften it a little bit. I think being able to realize that and having staff here realizing it has gone a long way. And just since I've been a resident, you know, I am now the fourth PD of the program,

so I think really it starts at the leadership position and then that just trickles down to the other staff, to then to senior residents, and then to junior residents. Well, thank you both for doing this important work and thank you for coming on this show to share some of your findings. I really appreciate it. It's so great to have people working hard to make the culture of surgical training better for the generations that come behind us. Yeah, for sure. Thank you for having us, Steve. Thank you for having us.